@article{spurlock_sewell_sugg_runkle_mercado_tyson_russell_2024, title={A spatial analysis of power-dependent medical equipment and extreme weather risk in the southeastern United States (vol 95, 103844, 2023)}, volume={103}, ISSN={["2212-4209"]}, DOI={10.1016/j.ijdrr.2024.104306}, journal={INTERNATIONAL JOURNAL OF DISASTER RISK REDUCTION}, author={Spurlock, Taylin and Sewell, Kelly and Sugg, Margaret M. and Runkle, Jennifer D. and Mercado, Rodrigo and Tyson, Jennifer Schroeder and Russell, Jamie}, year={2024}, month={Mar} }
 @article{runkle_sugg_berry_reed_cowan_wertis_ryan_2024, title={Association of Psychiatric Emergency Visits and Warm Ambient Temperature during Pregnancy: A Time-Stratified Case-Crossover Study}, volume={132}, ISSN={["1552-9924"]}, DOI={10.1289/EHP13293}, abstractNote={Acute exposure to high ambient temperature and heat waves during the warm season has been linked with psychiatric disorders. Emerging research has shown that pregnant people, due to physiological and psychological changes, may be more sensitive to extreme heat, and acute exposure has been linked to increased risk of pregnancy complications; however, few studies have examined psychiatric complications.}, number={6}, journal={ENVIRONMENTAL HEALTH PERSPECTIVES}, author={Runkle, Jennifer D. and Sugg, Margaret M. and Berry, Anne and Reed, Charlie and Cowan, Kristen and Wertis, Luke and Ryan, Sophie}, year={2024}, month={Jun} }
 @article{williamson_sugg_singh_green_runkle_2024, title={Crisis response in Texas youth impacted by Hurricane Harvey: A difference-in-differences analysis}, volume={359}, ISSN={["1573-2517"]}, DOI={10.1016/j.jad.2024.05.080}, abstractNote={Hurricane Harvey was the second costliest storm to impact the U.S. More research is needed to understand the mental health consequences of these extreme events in children and adolescents extending beyond the acute recovery period. Daily anonymized Crisis Text Line (CTL) conversations were used to understand patterns in crisis responses for youth one year before and after Harvey's landfall. A quasi-experimental difference-in-differences analysis compared changes in texts for stress/anxiety, depression, thoughts of suicide, and self-harm following Harvey between exposed and unexposed youth in Texas. CTL users with Texas-based area codes (N = 23,016) were compriesd largely of youth who self-identified as female (78.1 %), 14–17 year old (50.4 %), white (38.9 %), and LGBTQ+ (51.2 %). We observed parallel increases in crisis texts for depression and thoughts of suicide in most months following Harvey among exposed and unexposed youth. However, non-impacted youth had significantly larger increases in texts for depression up to three months post-Harvey and thoughts of suicide one year after Harvey compared to directly impacted communities. Sample size was restricted to texters who completed the post-conversation demographics survey, who may fundamentally differ from those who declined to respond. Harvey exposure was determined using texter area code and county-level disaster declarations, limiting our ability to guarantee individual-level exposure. Texas youth traditionally considered unexposed experienced nearly identical increases in concerns of depression and thoughts of suicide to those directly exposed. Findings suggest spillover effects (e.g., economic concerns, media exposure) may contribute to statewide impacts on youth mental health after natural disasters.}, journal={JOURNAL OF AFFECTIVE DISORDERS}, author={Williamson, Trey and Sugg, Margaret M. and Singh, Devyani and Green, Shannon and Runkle, Jennifer D.}, year={2024}, month={Aug}, pages={215–223} }
 @article{ulrich_sugg_desjardins_runkle_2024, title={Disparities in spatiotemporal clustering of maternal mental health conditions before and during the COVID-19 pandemic}, volume={89}, ISSN={["1873-2054"]}, DOI={10.1016/j.healthplace.2024.103307}, abstractNote={Mounting evidence indicates the worsening of maternal mental health conditions during the COVID-19 pandemic. Mental health conditions are the leading cause of preventable death during the perinatal and postpartum periods. Our study sought to detect space-time patterns in the distribution of maternal mental health conditions in pregnant women before (2016-2019) and during (2020-2021) the COVID-19 pandemic in North Carolina, USA. Using the space-time Poisson model in SaTScan, we performed univariate and multivariate cluster analysis of emergency department (ED) visits for perinatal mood and anxiety disorders (PMAD), severe mental illness (SMI), maternal mental disorders of pregnancy (MDP), suicidal thoughts, and suicide attempts during the pre-pandemic and pandemic periods. Clusters were adjusted for age, race, and insurance type. Significant multivariate and univariate PMAD, SMI, and MDP clustering persisted across both periods in North Carolina, while univariate clustering for both suicide outcomes decreased during the pandemic. Local relative risk (RR) for all conditions increased drastically in select locations. The number of zip code tabulation areas (ZCTAs) included in clusters decreased, while the proportion of urban locations included in clusters increased for non-suicide outcomes. Average yearly case counts for all maternal mental health outcomes increased during the pandemic. Results provide contextual and spatial information concerning at-risk maternal populations with a high burden of perinatal mental health disorders before and during the pandemic and emphasize the necessity of urgent and targeted expansion of mental health resources in select communities.}, journal={HEALTH & PLACE}, author={Ulrich, Sarah E. and Sugg, Margaret M. and Desjardins, Michael R. and Runkle, Jennifer D.}, year={2024}, month={Sep} }
 @article{sewell_paul_de polt_sugg_leeper_rao_runkle_2024, title={Impacts of compounding drought and heatwave events on child mental health: insights from a spatial clustering analysis}, volume={4}, ISSN={["2731-4383"]}, DOI={10.1007/s44192-023-00055-0}, abstractNote={Abstract Background Concurrent heatwave and drought events may have larger health impacts than each event separately; however, no US-based studies have examined differential mental health impacts of compound drought and heatwave events in pediatric populations. Objective To examine the spatial patterns of mood disorders and suicide-related emergency department (ED) visits in children during heatwave, drought, and compound heatwave and drought events. We tested whether the occurrence of compound heatwave and drought events have a synergistic (multiplicative) effect on the risk of mental health related outcomes in children as compared to the additive effect of each individual climate hazard. Lastly, we identified household and community-level determinants of geographic variability of high psychiatric burden. Methods Daily counts of psychiatric ED visits in North Carolina from 2016 to 2019 (May to Sept) for pediatric populations were aggregated at the county scale. Bernoulli cluster analyses identified high-risk spatial clusters of psychiatric morbidity during heatwave, drought, or compound heatwave and drought periods. Multivariate adaptive regression models examined the individual importance of household and community-level determinants in predicting high-risk clustering of mood disorders or suicidality across the three climate threats. Results Results showed significant spatial clustering of suicide and mood disorder risks in children during heatwave, drought, and compound event periods. Periods of drought were associated with the highest likelihood of spatial clustering for suicide and mood disorders, where the risk of an ED visit was 4.48 and 6.32 times higher, respectively, compared to non-drought periods. Compounding events were associated with a threefold increase in both suicide and mood disorder-related ED visits. Community and household vulnerability factors that most contributed to spatial clustering varied across climate hazards, but consistent determinants included residential segregation, green space availability, low English proficiency, overcrowding, no broadband access, no vehicle access, housing vacancy, and availability of housing units. Conclusion Findings advance understanding on the locations of vulnerable pediatric populations who are disproportionately exposed to compounding climate stressors and identify community resilience factors to target in public health adaptation strategies.}, number={1}, journal={DISCOVER MENTAL HEALTH}, author={Sewell, Kelly and Paul, Sudeshna and De Polt, Kelley and Sugg, Maggie M. and Leeper, Ronald D. and Rao, Douglas and Runkle, Jennifer D.}, year={2024}, month={Jan} }
 @article{ryan_sugg_runkle_wertis_singh_green_2024, title={Short-term changes in mental health help-seeking behaviors following exposure to multiple social stressors and a natural disaster}, volume={348}, ISSN={["1873-5347"]}, DOI={10.1016/j.socscimed.2024.116843}, abstractNote={2020 was an unprecedented year that uncovered glaring mental health crises. Individuals faced mental health stressors that extended beyond the devastating impact of the COVID-19 pandemic, including widespread social unrest following the murder of George Floyd, an intense hurricane season in the Atlantic, and the politically divisive 2020 election. The objective of this analysis was to consider changes in help-seeking behavior following exposure to multiple social stressors and a natural disaster. Data from Crisis Text Line (CTL), a national text-based mental health crisis counseling service, was used to determine how help-seeking behavior changed in the wake of each event. Wilcoxon rank sum tests assessed changes in help-seeking behavior for each event in 2020 as compared to the same period in 2019. Auto Regressive Integrated Moving Average (ARIMA) models examined if changes in crisis conversation volumes following each event differed. Higher median conversation volumes noted for the COVID-19 pandemic (+1 to +5 conversations), Hurricane Laura (+1 to +7 conversations) and the 2020 Election (+1 to +26 conversations). ARIMA models show substantial increases in help-seeking behavior following the declaration of a national emergency for the COVID-19 pandemic (+4.3 to +38.2%) and following the 2020 election (+3 to +24.44%). Our analysis found that the mental health response following social stressors may be distinct from natural events, especially when natural disasters occur in the context of multiple social stressors. This analysis adds to the growing body of literature considering the mental health impact of exposure to multiple co-occurring societal stressors, like police violence and a global pandemic.}, journal={SOCIAL SCIENCE & MEDICINE}, author={Ryan, Sophia C. and Sugg, Margaret M. and Runkle, Jennifer D. and Wertis, Luke and Singh, Devyani and Green, Shannon}, year={2024}, month={May} }
 @article{sugg_runkle_ryan_wertis_2023, title={A difference-in difference analysis of the South Carolina 2015 extreme floods and the association with maternal health}, volume={97}, ISSN={["2212-4209"]}, DOI={10.1016/j.ijdrr.2023.104037}, abstractNote={Research documenting the public health impacts of natural disasters often focuses on adults and children. Little research has examined the influence of extreme events, like floods, on maternal health, and less has examined the effect of disasters on maternal indicators like severe maternal morbidity (SMM) or unexpected outcomes of labor and delivery. The aim of this study is to identify the impacts of the 2015 flood events on maternal health outcomes in South Carolina, USA. We employ a quasi-experimental design using a difference-in-difference analysis with log-binomial regressions to evaluate outcomes for impacted and control locations during the disaster event. Unlike previous studies, we extended our difference-in-difference analysis to include a trimester of exposure to assess the timing of flood exposure. We did not find evidence of statistically significant main effects on maternal health from the 2015 flood events related to preterm birth, gestational diabetes, mental disorders of pregnancy, depression, and generalized anxiety. However, we did find a statistically significant increase in SMM and low birth weight during the flood event for women in select trimester periods who were directly exposed. Our work provides new evidence on the effects of extreme flood events, like the 2015 floods, which can impact maternal health during specific exposure periods of pregnancy. Additional research is needed across other extreme weather events, as the unique context of the 2015 floods limits the generalizability of our findings.}, journal={INTERNATIONAL JOURNAL OF DISASTER RISK REDUCTION}, author={Sugg, Margaret M. . and Runkle, Jennifer D. . and Ryan, Sophia C. . and Wertis, Luke}, year={2023}, month={Oct} }
 @article{spurlock_sewell_sugg_runkle_mercado_tyson_russell_2023, title={A spatial analysis of power-dependent medical equipment and extreme weather risk in the southeastern United States}, volume={95}, ISSN={["2212-4209"]}, DOI={10.1016/j.ijdrr.2023.103844}, abstractNote={Extreme weather events endanger critical health infrastructure, and many individuals rely on infrastructure to meet their basic needs, such as heat, water, and medical devices. The purpose of this study is to identify spatially explicit at-risk populations for power outages due to these extreme weather events. To accomplish this, we used the HHS emPOWER Emergency Planning Dataset, which was created to help public health authorities plan for and address the needs of communities. Using Geographic Information Systems (GIS), we overlay emPOWER data with the frequency of extreme weather events, including wildfires, hurricanes, tornadoes, and ice storms. Through our analysis, we identified vulnerable areas for high rates of disasters and electricity-dependent durable medical equipment (DME) to be located in communities along the coast. We also found a higher concentration of DME in rural areas compared to urban areas. In addition, we found least privileged economic locations are disproportionately vulnerable to power outages in the southeastern United States due to their high concentration of DME individuals. These results will inform public health officials where to target interventions to ensure continuity of care for vulnerable populations during power outages at the community level.}, journal={INTERNATIONAL JOURNAL OF DISASTER RISK REDUCTION}, author={Spurlock, Taylin and Sewell, Kelly and Sugg, Margaret M. and Runkle, Jennifer D. and Mercado, Rodrigo and Tyson, Jennifer Schroeder and Russell, Jamie}, year={2023}, month={Sep} }
 @article{duncan_reed_spurlock_sugg_runkle_2023, title={Acute Health Effects of Wildfire Smoke Exposure During a Compound Event: A Case-Crossover Study of the 2016 Great Smoky Mountain Wildfires}, volume={7}, ISSN={["2471-1403"]}, DOI={10.1029/2023GH000860}, abstractNote={AbstractIn 2016, unprecedented intense wildfires burned over 150,000 acres in the southern Appalachian Mountains in the United States. Smoke from these fires greatly impacted the region and exposure to this smoke was significant. A bidirectional case‐crossover design was applied to assess the relationship between PM2.5 (a surrogate for wildfire smoke) exposure and respiratory‐ and cardiovascular‐related emergency department (ED) visits in Western North Carolina during these events. For 0‐, 3‐, and 7‐day lags, findings indicated a significant increase in the odds of being admitted to the ED for a respiratory (ORs: 1.055, 95% CI: 1.048–1.063; 1.083, 1.074–1.092; 1.066, 1.058–1.074; respectively) or cardiovascular event (ORs: 1.052, 95% CI: 1.045–1.060; 1.074, 1.066–1.081; 1.067, 1.060–1.075; respectively) for every 5 μg/m3 increase in PM2.5 over a chosen cutpoint of 20.4 μg/m3. For all endpoints assessed except for emphysema, there were statistically significant increases in odds from 5.1% to 8.3%. In general, this increase was most pronounced 3 days after exposure. Additionally, individuals aged 55+ generally experience higher odds of heart disease at the 3‐ and 7‐day lag points, and Black/African Americans generally experience higher odds of asthma at the 3‐day lag point. In general, larger fires and increased numbers of fires within counties resulted in higher health burden at same day exposure. In a secondary analysis, the odds of an ED visit increased by over 40% in several cases among people exposed to days above the Environmental Protection Agency 24‐hr PM2.5 standard of 35 μg/m3. Our findings provide new understanding on the health impacts of wildfires on rural populations in the southeastern US.}, number={10}, journal={GEOHEALTH}, author={Duncan, Sara and Reed, Charlie and Spurlock, Taylin and Sugg, Margaret M. and Runkle, Jennifer D.}, year={2023}, month={Oct} }
 @article{murray_lavery_schaeffer_seegers_pennington_hilborn_boerger_runkle_loftin_graham_et al._2024, title={Assessing the relationship between cyanobacterial blooms and respiratory-related hospital visits: Green bay, Wisconsin 2017-2019}, volume={255}, ISSN={["1618-131X"]}, DOI={10.1016/j.ijheh.2023.114272}, abstractNote={Potential acute and chronic human health effects associated with exposure to cyanobacteria and cyanotoxins, including respiratory symptoms, are an understudied public health concern. We examined the relationship between estimated cyanobacteria biomass and the frequency of respiratory-related hospital visits for residents living near Green Bay, Lake Michigan, Wisconsin during 2017-2019. Remote sensing data from the Cyanobacteria Assessment Network was used to approximate cyanobacteria exposure through creation of a metric for cyanobacteria chlorophyll-a (ChlBS). We obtained counts of hospital visits for asthma, wheezing, and allergic rhinitis from the Wisconsin Hospital Association for ZIP codes within a 3-mile radius of Green Bay. We analyzed weekly counts of hospital visits versus cyanobacteria, which was modelled as a continuous measure (ChlBS) or categorized according to World Health Organization's (WHO) alert levels using Poisson generalized linear models. Our data included 2743 individual hospital visits and 114 weeks of satellite derived cyanobacteria biomass indicator data. Peak values of ChlBS were observed between the months of June and October. Using the WHO alert levels, 60% of weeks were categorized as no risk, 19% as Vigilance Level, 15% as Alert Level 1, and 6% as Alert Level 2. In Poisson regression models adjusted for temperature, dewpoint, season, and year, there was no association between ChlBS and hospital visits (rate ratio [RR] [95% Confidence Interval (CI)] = 0.98 [0.77, 1.24]). There was also no consistent association between WHO alert level and hospital visits when adjusting for covariates (Vigilance Level: RR [95% CI] 0.88 [0.74, 1.05], Alert Level 1: 0.82 [0.67, 0.99], Alert Level 2: 0.98 [0.77, 1.24], compared to the reference no risk category). Our methodology and model provide a template for future studies that assess the association between cyanobacterial blooms and respiratory health.}, journal={INTERNATIONAL JOURNAL OF HYGIENE AND ENVIRONMENTAL HEALTH}, author={Murray, Jordan F. and Lavery, Amy M. and Schaeffer, Blake A. and Seegers, Bridget N. and Pennington, Audrey F. and Hilborn, Elizabeth D. and Boerger, Savannah and Runkle, Jennifer D. and Loftin, Keith and Graham, Jennifer and et al.}, year={2024}, month={Jan} }
 @article{runkle_risley_roy_sugg_2023, title={Association Between Perinatal Mental Health and Pregnancy and Neonatal Complications: A Retrospective Birth Cohort Study}, volume={33}, ISSN={["1878-4321"]}, DOI={10.1016/j.whi.2022.12.001}, abstractNote={Background Maternal mental health as an important precursor to reproductive and neonatal complications remains understudied in the United States, particularly in the Southeastern region, despite high medical costs, maternal morbidity, and infant burden. This study sought to estimate the incidence of perinatal mental health disorders and the associated increased risk of leading pregnancy and infant complications. Methods A population-based retrospective birth cohort of childbirth hospitalizations and readmissions was constructed for women in South Carolina, 1999 to 2017. Prevalence rates were calculated for perinatal mood and anxiety disorders (PMAD), severe mental illness, and mental disorders of pregnancy (MDP). Poisson regression models using generalized estimating equations were used to estimate adjusted relative risks for the association between mental health conditions and severe maternal morbidity, hypertensive disorders of pregnancy, gestational diabetes, cesarean section, preterm birth, and low birthweight. Results The most prevalent maternal mental condition was MDP (3.9%), followed by PMAD (2.7%) and severe mental illness (0.13%). PMAD was associated with a higher risk of severe maternal morbidity, hypertensive disorders of pregnancy, and cesarean section, as well as a higher risk of preterm birth and low birthweight infants. Severe mental illness was associated with low birthweight, hypertensive disorders of pregnancy, and cesarean section. Pregnant populations with MDP were more at risk for severe maternal morbidity, preterm birth, hypertensive disorders of pregnancy, low birthweight, and cesarean section. Each maternal mental health outcome was associated with an increased risk for hospital readmissions up to 45 days after childbirth. Conclusions Results demonstrate the escalating burden of PMAD and MDP for pregnant populations over time, with important consequences related to maternal and infant morbidity.}, number={3}, journal={WOMENS HEALTH ISSUES}, author={Runkle, Jennifer D. and Risley, Kendra and Roy, Manan and Sugg, Margaret M.}, year={2023}, pages={289–299} }
 @article{ryan_sugg_runkle_2023, title={Association between urban greenspace, tree canopy cover and intentional deaths: An exploratory geospatial analysis}, volume={86}, ISSN={["1610-8167"]}, DOI={10.1016/j.ufug.2023.128015}, abstractNote={Greenspaces can provide restorative experiences, offer opportunities for outdoor recreation, and reduce mental fatigue; all of which may improve community health and safety. Yet few studies have examined the neighborhood-level benefits of greenspace in reducing violent deaths. This study explored the association between three distinct greenspace metrics: public greenspace quantity, public greenspace accessibility, neighborhood tree canopy cover, and intentional deaths (i.e., homicides and suicides). Generalized linear models and spatial error models investigated the association between greenspace, tree canopy and intentional deaths in three geographically distinct cities in North Carolina. Results revealed that increased neighborhood greenspace accessibility and tree canopy cover were associated with reduced intentional deaths in all three urban areas. Neighborhood greenspace accessibility was the most protective factor across all study areas. The relationship between neighborhood greenspace accessibility and intentional deaths was more significant for non-firearm deaths as compared to firearm deaths, indicating that weapon type may be an important consideration for neighborhood greenspace interventions. Compared to predominantly White neighborhoods, predominantly Black neighborhoods had higher rates of homicide in Asheville and Durham and higher rates of suicide in Charlotte. Future policy and research should focus on improving equitable access to existing and future greenspaces, especially in primarily Black neighborhoods.}, journal={URBAN FORESTRY & URBAN GREENING}, author={Ryan, Sophia C. and Sugg, Margaret M. and Runkle, Jennifer D.}, year={2023}, month={Aug} }
 @article{sugg_wertis_ryan_green_singh_runkle_2023, title={Cascading disasters and mental health: The February 2021 winter storm and power crisis in Texas, USA}, volume={880}, ISSN={["1879-1026"]}, DOI={10.1016/j.scitotenv.2023.163231}, abstractNote={In February 2021, the state of Texas and large parts of the US were affected by a severe cold air outbreak and winter weather event. This event resulted in large-scale power outages and cascading impacts, including limited access to potable water, multiple days without electricity, and large-scale infrastructure damage. Little is known about the mental health implications of these events, as most research has predominantly focused on the mental health effects of exposure to hurricanes, wildfires, or other natural disasters that are more commonly found in the summer months. This study aimed to analyze the crisis responses from the 2021 winter weather event in Texas using Crisis Text Line, a text-based messaging service that provides confidential crisis counseling nationwide. To date, Crisis Text Line is the largest national crisis text service, with over 8 million crisis conversations since its inception in 2013. We employed multiple analytic techniques, including segmented regression, interrupted time series, autoregressive integrated moving average (ARIMA), and difference-in-difference (DID), to investigate distinct time periods of exposure for all crisis conversations. ARIMA and DID were further utilized to examine specific crisis outcomes, including depression, stress/anxiety, and thoughts of suicide. Results found increases in total crisis conversations and for thoughts of suicide after the initial winter weather event; however, crisis outcomes varied in time. Thoughts of suicide in high-impact regions were higher across multiple time periods (e.g., 4-weeks, 3-months, 6-months, 9-months and 11-months) compared to low-impact regions and were elevated compared to pre-event time periods for 6-months and 11-months from the initial event. Total crisis volume also remained elevated for high-impact regions compared to low-impact regions up to 11-months after the beginning of the winter event. Our work highlights that cascading winter weather events, like the Texas 2021 Winter storm, negatively impacted mental health. Future research is needed across different disaster types (e.g., cascading, concurrent events) and for specific crisis outcomes (e.g., depression, suicidal ideation) to understand the optimal timing of crisis intervention post-disaster.}, journal={SCIENCE OF THE TOTAL ENVIRONMENT}, author={Sugg, Margaret M. and Wertis, Luke and Ryan, Sophia C. and Green, Shannon and Singh, Devyani and Runkle, Jennifer D.}, year={2023}, month={Jul} }
 @article{sugg_ryan_spurlock_duncan_hege_ogwu_tyson_shay_renwick_hendren_et al._2023, title={Climate change and health in rural mountain environments: summary of a workshop on knowledge gaps, barriers, and opportunities for action}, ISSN={["1572-9893"]}, DOI={10.1007/s10708-023-10916-4}, journal={GEOJOURNAL}, author={Sugg, Margaret Mae and Ryan, Sophia and Spurlock, Taylin and Duncan, Sara and Hege, Adam and Ogwu, Matthew Chidozie and Tyson, Jennifer and Shay, Elizabeth and Renwick, Kelly Ann and Hendren, Christine and et al.}, year={2023}, month={Aug} }
 @article{sugg_runkle_ryan_singh_green_thompson_2023, title={Crisis Response and Suicidal Behaviors of Essential Workers and Children of Essential Workers During the COVID-19 Pandemic}, ISSN={["1468-2877"]}, DOI={10.1177/00333549221148177}, abstractNote={Objective: The COVID-19 pandemic has put unprecedented stress on essential workers and their children. Limited cross-sectional research has found increases in mental health conditions from workload, reduced income, and isolation among essential workers. Less research has been conducted on children of essential workers. We examined trends in the crisis response of essential workers and their children from April 2020 through August 2021. Methods: We investigated the impact during 3 periods of the pandemic on workers and their children using anonymized data from the Crisis Text Line on crisis help-seeking texts for thoughts of suicide or active suicidal ideation (desire, intent, capability, time frame), abuse (emotional, physical, sexual, unspecified), anxiety/stress, grief, depression, isolation, bullying, eating or body image, gender/sexual identity, self-harm, and substance use. We used generalized estimating equations to study the longitudinal change in crisis response across the later stages of the pandemic using adjusted odds ratios (aORs) for worker status and crisis outcomes. Results: Results demonstrated higher odds of crisis outcomes for thoughts of suicide (aOR = 1.06; 95% CI, 1.00-1.12) and suicide capability (aOR = 1.14; 95% CI, 1.02-1.27) among essential workers than among nonessential workers. Children of essential workers had higher odds of substance use than children of nonessential workers (aOR = 1.33; 95% CI, 1.08-1.65), particularly for Indigenous American children (aOR = 2.76; 95% CI, 1.35-5.36). Essential workers (aOR = 1.17; 95% CI, 1.07-1.27) and their children (aOR = 1.18; 95% CI, 1.07-1.30) had higher odds of grief than nonessential workers and their children. Conclusion: Essential workers and their children had elevated crisis outcomes. Immediate and low-cost psychologically supportive interventions are needed to mitigate the mental health impacts of the COVID-19 pandemic on these populations. }, journal={PUBLIC HEALTH REPORTS}, author={Sugg, Margaret M. M. and Runkle, Jennifer D. D. and Ryan, Sophia C. C. and Singh, Devyani and Green, Shannon and Thompson, Martie}, year={2023}, month={Jan} }
 @article{ryan_desjardins_runkle_wertis_sugg_2023, title={Evaluating co-occurring space-time clusters of depression and suicide-related outcomes before and during the COVID-19 pandemic}, volume={47}, ISSN={["1877-5853"]}, DOI={10.1016/j.sste.2023.100607}, abstractNote={Rapidly emerging research on the mental health consequences of the COVID-19 pandemic shows increasing patterns of psychological distress, including anxiety and depression, and self-harming behaviors, particularly during the early months of the pandemic. Yet, few studies have investigated the spatial and temporal changes in depressive disorders and suicidal behavior during the pandemic. The objective of this retrospective analysis was to evaluate geographic patterns of emergency department admissions for depression and suicidal behavior in North Carolina before (March 2017-February 2020) and during the COVID-19 pandemic (March 2020 - December 2021). Univariate cluster detection examined each outcome separately and multivariate cluster detection was used to examine the co-occurrence of depression and suicide-related outcomes in SatScan; the Rand index evaluated cluster overlap. Cluster analyses were adjusted for age, race, and sex. Findings suggest that the mental health burden of depression and suicide-related outcomes remained high in many communities throughout the pandemic. Rural communities exhibited a larger increase in the co-occurrence of depression and suicide-related ED visits during the pandemic period. Results showed the exacerbation of depression and suicide-related outcomes in select communities and emphasize the need for targeted and sustained mental health interventions throughout the many phases of the COVID-19 pandemic.}, journal={SPATIAL AND SPATIO-TEMPORAL EPIDEMIOLOGY}, author={Ryan, Sophia C. and Desjardins, Michael R. and Runkle, Jennifer D. and Wertis, Luke and Sugg, Margaret M.}, year={2023}, month={Nov} }
 @article{wertis_runkle_sugg_singh_2023, title={Examining Hurricane Ida's Impact on Mental Health: Results From a Quasi-Experimental Analysis}, volume={7}, ISSN={["2471-1403"]}, DOI={10.1029/2022GH000707}, abstractNote={AbstractLimited research has evaluated the mental health effects during compounding disasters (e.g., a hurricane occurring during a pandemic), and few studies have examined post‐disaster mental health with alternative data sources like crisis text lines. This study examined changes in crisis help‐seeking for individuals in Louisiana, USA, before and after Hurricane Ida (2021), a storm that co‐occurred during the COVID‐19 pandemic. An interrupted time series analysis and difference‐in‐difference analysis for single and multiple group comparisons were used to examine pre‐and post‐changes in crisis text volume (i.e., any crisis text, substance use, thoughts of suicide, stress/anxiety, and bereavement) among help‐seeking individuals in communities that received US Federal Emergency Management Agency individual and public assistance following a presidential disaster declaration. Results showed a significant increase in crisis texts for any reason, thoughts of suicide, stress/anxiety, and bereavement in the four‐week, three‐month, and four‐month post‐impact period. Findings highlight the need for more mental health support for residents directly impacted by disasters like Hurricane Ida.}, number={2}, journal={GEOHEALTH}, author={Wertis, Luke and Runkle, Jennifer D. and Sugg, Margaret M. and Singh, Devyani}, year={2023}, month={Feb} }
 @article{ulrich_sugg_ryan_runkle_2023, title={Mapping high-risk clusters and identifying place-based risk factors of mental health burden in pregnancy}, volume={4}, ISSN={["2666-5603"]}, DOI={10.1016/j.ssmmh.2023.100270}, abstractNote={Despite affecting up to 20% of women and being the leading cause of preventable deaths during the perinatal and postpartum period, maternal mental health conditions are chronically understudied. This study is the first to identify spatial patterns in perinatal mental health conditions, and relate these patterns to place-based social and environmental factors that drive cluster development. Among recorded hospital births from 2016 to 2019 in North Carolina, we performed spatial clustering analysis of emergency department (ED) visits for perinatal mood and anxiety disorders (PMAD), severe mental illness (SMI), and maternal mental disorders of pregnancy (MDP) using the Poisson model in SatScan. Logistic regression was used to examine the association of patient and community-level factors with high-risk clusters. The most significant spatial clustering for all three outcomes was concentrated in smaller urban areas in the western, central piedmont, and coastal plains regions of the state, with rate ratios greater than 3 for some cluster locations. Individual factors (e.g., age, race, ethnicity) and contextual factors racial and socioeconomic segregation, urbanity, access to healthcare services, insurance, food security, and access to greenspace) were associated with high risk clusters. Results provide important contextual and spatial information concerning at-risk populations with a high burden of maternal mental health disorders and can better inform targeted locations for the expansion of maternal mental health services.}, journal={SSM-MENTAL HEALTH}, author={Ulrich, Sarah E. and Sugg, Margaret M. and Ryan, Sophia C. and Runkle, Jennifer D.}, year={2023}, month={Dec} }
 @article{kramer_labgold_zertuche_runkle_bryan_freymann_austin_adams_dunlop_2023, title={Severe Maternal Morbidity in Georgia, 2009-2020}, volume={61}, ISSN={["1537-1948"]}, DOI={10.1097/MLR.0000000000001819}, abstractNote={
            Background:
            The increasing focus of population surveillance and research on maternal—and not only fetal and infant—health outcomes is long overdue. The United States maternal mortality rate is higher than any other high-income country, and Georgia is among the highest rates in the country. Severe maternal morbidity (SMM) is conceived of as a “near miss” for maternal mortality, is 50 times more common than maternal death, and efforts to systematically monitor SMM rates in populations have increased in recent years. Much of the current population-based research on SMM has occurred in coastal states or large cities, despite substantial geographical variation with higher maternal and infant health burdens in the Southeast and rural regions.
          
          
            Methods:
            This population-based study uses hospital discharge records linked to vital statistics to describe the epidemiology of SMM in Georgia between 2009 and 2020.
          
          
            Results:
            Georgia had a higher SMM rate than the United States overall (189.2 vs. 144 per 10,000 deliveries in Georgia in 2014, the most recent year with US estimates). SMM was higher among racially minoritized pregnant persons and those at the extremes of age, of lower socioeconomic status, and with comorbid chronic conditions. SMM rates were 5 to 6 times greater for pregnant people delivering infants <1500 grams or <32 weeks’ gestation as compared with those delivering normal weight or term infants. Since 2015, SMM has increased in Georgia.
          
          
            Conclusion:
            SMM represents a collection of life-threatening emergencies that are unevenly distributed in the population and require increased attention. This descriptive analysis provides initial guidance for programmatic interventions intending to reduce the burden of SMM and, subsequently, maternal mortality in the US South.
          }, number={5}, journal={MEDICAL CARE}, author={Kramer, Michael R. and Labgold, Katie and Zertuche, Adrienne D. and Runkle, Jennifer D. and Bryan, Michael and Freymann, Gordon R. and Austin, David and Adams, E. Kathleen and Dunlop, Anne L.}, year={2023}, month={May}, pages={258–267} }
 @article{minor_sugg_runkle_2023, title={Short-term exposure to temperature and mental health in North Carolina: a distributed lag nonlinear analysis}, ISSN={["1432-1254"]}, DOI={10.1007/s00484-023-02436-0}, abstractNote={Adverse mental health outcomes have been associated with high temperatures in studies worldwide. Few studies explore a broad range of mental health outcomes, and to our knowledge, none are specific to NC, USA. This ecological study explored the relationship between ambient temperature and mental health outcomes (suicide, self-harm and suicide ideation, anxiety and stress, mood disorders, and depression) in six urban counties across the state of NC, USA. We applied a quasi-Poisson generalized linear model combined with a distributed lag nonlinear model (DLNM) to examine the short-term effects of daily ambient temperature on emergency admissions for mental health conditions (2016 to 2018) and violent deaths (2004 to 2018). The results were predominately insignificant, with some key exceptions. The county with the greatest temperature range (Wake) displays higher levels of significance, while counties with the lowest temperature ranges (New Hanover and Pitt) are almost entirely insignificant. Self-harm and suicidal ideation peak in the warm months (July) and generally exhibit a protective effect at lower temperatures and shorter lag intervals. Whereas anxiety, depression, and major depressive disorders peak in the cooler months (May and September). Suicide is the only outcome that favored a 20-day lag period in the sensitivity analysis, although the association with temperature was insignificant. Our findings suggest additional research is needed across a suite of mental health outcomes to fully understand the effects of temperatures on mental health.}, journal={INTERNATIONAL JOURNAL OF BIOMETEOROLOGY}, author={Minor, Tyler and Sugg, Margaret and Runkle, Jennifer D.}, year={2023}, month={Feb} }
 @article{wertis_sugg_runkle_rao_2023, title={Socio-Environmental Determinants of Mental and Behavioral Disorders in Youth: A Machine Learning Approach}, volume={7}, ISSN={["2471-1403"]}, url={http://dx.doi.org/10.1029/2023gh000839}, DOI={10.1029/2023GH000839}, abstractNote={AbstractGrowing evidence indicates that extreme environmental conditions in summer months have an adverse impact on mental and behavioral disorders (MBD), but there is limited research looking at youth populations. The objective of this study was to apply machine learning approaches to identify key variables that predict MBD‐related emergency room (ER) visits in youths in select North Carolina cities among adolescent populations. Daily MBD‐related ER visits, which totaled over 42,000 records, were paired with daily environmental conditions, as well as sociodemographic variables to determine if certain conditions lead to higher vulnerability to exacerbated mental health disorders. Four machine learning models (i.e., generalized linear model, generalized additive model, extreme gradient boosting, random forest) were used to assess the predictive performance of multiple environmental and sociodemographic variables on MBD‐related ER visits for all cities. The best‐performing machine learning model was then applied to each of the six individual cities. As a subanalysis, a distributed lag nonlinear model was used to confirm results. In the all cities scenario, sociodemographic variables contributed the greatest to the overall MBD prediction. In the individual cities scenario, four cities had a 24‐hr difference in the maximum temperature, and two of the cities had a 24‐hr difference in the minimum temperature, maximum temperature, or Normalized Difference Vegetation Index as a leading predictor of MBD ER visits. Results can inform the use of machine learning models for predicting MBD during high‐temperature events and identify variables that affect youth MBD responses during these events.}, number={9}, journal={GEOHEALTH}, publisher={American Geophysical Union (AGU)}, author={Wertis, Luke and Sugg, Margaret M. and Runkle, Jennifer D. and Rao, Douglas}, year={2023}, month={Sep} }
 @article{ryan_sugg_runkle_matthews_2023, title={Spatial Analysis of Greenspace and Mental Health in North Carolina Consideration of Rural and Urban Communities}, volume={46}, ISSN={["1550-5057"]}, DOI={10.1097/FCH.0000000000000363}, abstractNote={Greenspace positively impacts mental health. Previous research has focused on the greenspace-mental health relationship in urban areas. Yet, little work has looked at rural areas despite rural communities reporting similar rates of poor mental health outcomes and higher rates of suicide mortality compared with urban areas. This ecological research study examined the following research questions: (1) Do public and/or private greenspaces affect the spatial distribution of mental health outcomes in North Carolina? (2) Does this relationship change with rurality? Emergency department data for 6 mental health conditions and suicide mortality data from 2009 to 2018 were included in this analysis. Spatial error and ordinary least squares regressions were used to examine the influence of public and private greenspace quantity on mental health in rural and urban communities. Results suggest greenspace benefits mental health in rural and urban communities. The strength of this relationship varies with urbanity and between public and private greenspaces, suggesting a more complex causal relationship. Given the high case counts and often lower density of mental health care facilities in rural areas, focusing attention on low-cost mental health interventions, such as greenspace, is important when considering rural mental health care.}, number={3}, journal={FAMILY & COMMUNITY HEALTH}, author={Ryan, Sophia C. and Sugg, Margaret M. and Runkle, Jennifer D. and Matthews, Jessica L.}, year={2023}, pages={181–191} }
 @article{harden_runkle_sugg_2022, title={An Exploratory Spatiotemporal Analysis of Socio-Environmental Patterns in Severe Maternal Morbidity}, ISSN={["1573-6628"]}, DOI={10.1007/s10995-021-03330-0}, abstractNote={Severe Maternal Morbidity (SMM) is a group of pregnancy complications in which a woman nearly dies. Despite its increasing prevalence, little research has evaluated geographic patterns of SMM and the underlying social determinants that influence excess risk. This study examined the spatial clustering of SMM across South Carolina, US, and its associations with place-based social and environmental factors.Hospitalized deliveries from 2012 to 2017 were analyzed using Kulldorff's spatial scan statistic to locate areas with abnormally high rates of SMM. SMM patients inside and outside risk clusters were compared using Generalized Estimating Equations (GEE) to determine underlying individual and community-level risk factors.GEE models revealed that the odds of living in a high-risk SMM21 (SMM including blood transfusions) cluster was 2.49 times higher among Black patients (p < .001) compared to those outside of a high-risk cluster. Women residing in a high-risk SMM20 (SMM excluding blood transfusions) cluster were 1.38 times more likely to experience the most number of extremely hot days and 1.70 times more likely to present with obesity than women in a low-risk SMM cluster (p < .001).This study is the first to characterize the geographic clustering of SMM risk in the US. Our geospatial approach contributes a novel understanding to factors which influence SMM beyond patient-level characteristics and identifies the impact of hot ambient temperature on maternal morbidity. Findings address an important literature gap surrounding place-based risk factors by explaining the contextual social and built environmental factors that drive SMM risk.}, journal={MATERNAL AND CHILD HEALTH JOURNAL}, author={Harden, Stella R. and Runkle, Jennifer D. and Sugg, Margaret M.}, year={2022}, month={Jan} }
 @article{moreno_sugg_runkle_leeper_perry_sugg_2022, title={Examining spatiotemporal trends of drought in the conterminous United States using self-organizing maps}, ISSN={["1930-0557"]}, DOI={10.1080/02723646.2022.2035891}, abstractNote={ABSTRACT Droughts are a natural, recurrent climate extreme that can inflict long-lasting devastation on natural ecosystems and socio-economic sectors. Unlike other natural hazards, drought onset is insidious and often affects a greater spatial extent over a prolonged temporal scale. In the United States the evolution of drought and its impacts are typically region-specific and intensified precipitation variability may obscure how drought may manifest. In this study, we examine the spatiotemporal trends of drought using self-organizing maps (SOM), competitive learning subset of artificial neural networks (ANN), requiring unsupervised training of inputs. We introduced monthly Palmer Drought Severity Index (PDSI) values to the SOM to identify existing clusters of wetting and drying patterns from 1895 to 2016. After training, we created cartographic visualizations of the SOM output and conducted a subsequent time-series analysis to link with the geographic patterns of drought. Over the last 40 years, precipitation intensified in the Northeast, Midwest, and upper Great Plains across several nodes. Across the majority of SOM patterns, we identified no significant changes of drying or wetting patterns over the last century for the greater part of the CONUS.}, journal={PHYSICAL GEOGRAPHY}, author={Moreno, Camila and Sugg, Johnathan and Runkle, Jennifer and Leeper, Ronald D. and Perry, L. Baker and Sugg, Margaret}, year={2022}, month={Feb} }
 @article{sugg_runkle_andersen_desjardins_2023, title={Exploring Place-Based Differences in Suicide and Suicide-Related Outcomes Among North Carolina Adolescents and Young Adults}, volume={72}, ISSN={["1879-1972"]}, DOI={10.1016/j.jadohealth.2022.06.013}, abstractNote={Suicide is an ongoing public health crisis among youth and adolescents, and few studies have investigated the spatial patterning in the United States among this subpopulation. Potential precursors to suicide in this vulnerable group are also on the rise, including nonfatal self-injury.This study uses emergency department data, death certificates, and violent death reporting system data for North Carolina from 2009 to 2018 to investigate spatial clusters of self-injury and suicide.Findings show that the demographic characteristics of individuals committing fatal and nonfatal self-injury are quite different. Self-injury and completed suicides exhibited different geographical patterns. Area-level measures like micropolitan status and measures of racial and income segregation predicted the presence of high-risk suicide clusters. Suicides among Native Americans and veteran status/military personnel also were associated with higher risk suicide clusters.Future interventions should target these specific high-risk locations for immediate reductions in adolescent and youth suicides.}, number={1}, journal={JOURNAL OF ADOLESCENT HEALTH}, author={Sugg, Margaret M. and Runkle, Jennifer D. and Andersen, Lauren M. and Desjardins, Michael R.}, year={2023}, month={Jan}, pages={27–35} }
 @article{hass_mccanless_cooper_ellis_fuhrmann_kintziger_sugg_runkle_2022, title={Heat exposure misclassification: Do current methods of classifying diurnal range in individually experienced temperatures and heat indices accurately reflect personal exposure?}, ISSN={["1432-1254"]}, DOI={10.1007/s00484-022-02280-8}, abstractNote={Wearable sensors have been used to collect information on individual exposure to excessive heat and humidity. To date, no consistent diurnal classification method has been established, potentially resulting in missed opportunities to understand personal diurnal patterns in heat exposure. Using individually experienced temperatures (IET) and heat indices (IEHI) collected in the southeastern United States, this work aims to determine whether current methods of classifying IETs and IEHIs accurately characterize "day," which is typically the warmest conditions, and "night," which is typically the coolest conditions. IET and IEHI data from four locations were compared with the closest hourly weather station. Different day/night classifications were compared to determine efficacy. Results indicate that diurnal IET and IEHI ranges are higher than fixed-site ranges. Maximum IETs and IEHIs are warmer and occur later in the day than ambient conditions. Minimum IETs are lower and occur earlier in the day than at weather stations, which conflicts with previous assumptions that minimum temperatures occur at night. When compared to commonly used classification methods, a method of classifying day and night based on sunrise and sunset times best captured the occurrence of maximum IETs and IEHIs. Maximum IETs and IEHIs are often identified later in the evening, while minimum IETs and IEHIs occur throughout the day. These findings support future research focusing on nighttime heat exposure, which can exacerbate heat-related health issues, and diurnal patterns of personal exposure throughout the entire day as individual patterns do not necessarily follow the diurnal pattern seen in ambient conditions.}, journal={INTERNATIONAL JOURNAL OF BIOMETEOROLOGY}, author={Hass, Alisa L. and McCanless, Kathryn and Cooper, Winton and Ellis, Kelsey and Fuhrmann, Christopher and Kintziger, Kristina W. and Sugg, Margaret and Runkle, Jennifer}, year={2022}, month={Apr} }
 @article{sugg_runkle_dow_barnes_stevens_pearce_bossak_curtis_2022, title={Individually experienced heat index in a coastal Southeastern US city among an occupationally exposed population}, ISSN={["1432-1254"]}, DOI={10.1007/s00484-022-02309-y}, abstractNote={Recent studies have characterized individually experienced temperatures or individually experienced heat indices, including new exposure metrics that capture dimensions of exposure intensity, frequency, and duration. Yet, few studies have examined the personal thermal exposure in underrepresented groups, like outdoor workers, and even fewer have assessed corresponding changes in physiologic heat strain. The objective of this paper is to examine a cohort of occupationally exposed grounds and public safety workers (n = 25) to characterize their heat exposure and resulting heat strain. In addition, a secondary aim of this work is to compare individually heat index exposure (IHIE) across exposure metrics, fixed-site in situ weather stations, and raster-derived urban heat island (UHI) measurements in Charleston, SC, a humid coastal climate in the Southeastern USA. A Bland-Altman (BA) analysis was used to assess the level of agreement between the personal IHIE measurements and weather-station heat index (HI) and Urban Heat Island (UHI) measurements. Linear mixed-effect models were used to determine the association between individual risk factors and in situ weather station measurements significantly associated with IHIE measurements. Multivariable stepwise Cox proportional hazard modeling was used to identify the individual and workplace factors associated with time to heat strain in workers. We also examined the non-linear association between heat strain and exposure metrics using generalized additive models. We found significant heterogeneity in IHIE measurements across participants. We observed that time to heat strain was positively associated with a higher IHIE, older age, being male, and among Caucasian workers. Important nonlinear associations between heat strain occurrence and the intensity, frequency, and duration of personal heat metrics were observed. Lastly, our analysis found that IHIE measures were significantly similar for weather station HI, although differences were more pronounced for temperature and relative humidity measurements. Conversely, our IHIE findings were much lower than raster-derived UHI measurements. Real-time monitoring can offer important insights about unfolding temperature-health trends and emerging behaviors during thermal extreme events, which have significant potential to provide situational awareness.}, journal={INTERNATIONAL JOURNAL OF BIOMETEOROLOGY}, author={Sugg, Margaret M. and Runkle, Jennifer D. and Dow, Kirstin and Barnes, Janice and Stevens, Scott and Pearce, John and Bossak, Brian and Curtis, Scott}, year={2022}, month={Jun} }
 @article{mitchell_runkle_andersen_shay_sugg_2022, title={Inequalities in Life Expectancy Across North Carolina A Spatial Analysis of the Social Determinants of Health and the Index of Concentration at Extremes}, volume={45}, ISSN={["1550-5057"]}, DOI={10.1097/FCH.0000000000000318}, abstractNote={Health inequalities are characterized by spatial patterns of social, economic, and political factors. Life expectancy (LE) is a commonly used indicator of overall population health and health inequalities that allows for comparison across different spatial and temporal regions. The objective of this study was to examine geographic inequalities in LE across North Carolina census tracts by comparing the performance of 2 popular geospatial health indices: Social Determinants of Health (SDoH) and the Index of Concentration at Extremes (ICE). A principal components analysis (PCA) was used to address multicollinearity among variables and aggregate data into components to examine SDoH, while the ICE was constructed using the simple subtraction of geospatial variables. Spatial regression models were employed to compare both indices in relation to LE to evaluate their predictability for population health. For individual SDoH and ICE components, poverty and income had the strongest positive correlation with LE. However, the common spatial techniques of adding PCA components together for a final SDoH aggregate measure resulted in a poor relationship with LE. Results indicated that both metrics can be used to determine spatial patterns of inequities in LE and that the ICE metric has similar success to the more computationally complex SDoH metric. Public health practitioners may find the ICE metric's high predictability matched with lower data requirements to be more feasible to implement in population health monitoring.}, number={2}, journal={FAMILY & COMMUNITY HEALTH}, author={Mitchell, Jessica H. and Runkle, Jennifer D. and Andersen, Lauren M. and Shay, Elizabeth and Sugg, Margaret M.}, year={2022}, pages={77–90} }
 @article{ryan_runkle_sugg_singh_green_wertis_2023, title={Spatio-Temporal Clustering of Adolescent Bereavement in the United States During the Extended Response to COVID-19: A Follow-Up Study}, volume={72}, ISSN={["1879-1972"]}, DOI={10.1016/j.jadohealth.2022.08.021}, abstractNote={This follow-up study investigated the spatio-temporal clustering of adolescent bereavement during the extended response to COVID-19 from October 2020-January 2022 in the continental United States.}, number={1}, journal={JOURNAL OF ADOLESCENT HEALTH}, author={Ryan, Sophia C. and Runkle, Jennifer D. and Sugg, Margaret M. and Singh, Devyani and Green, Shannon and Wertis, Luke}, year={2023}, month={Jan}, pages={156–159} }
 @article{runkle_yadav_michael_green_weiser_sugg_2022, title={Crisis Response and Suicidal Patterns in US Youth Before and During COVID-19: A Latent Class Analysis}, volume={70}, ISSN={["1879-1972"]}, DOI={10.1016/j.jadohealth.2021.10.003}, abstractNote={This study characterized the unobserved patterns in crisis response among youth in the U.S. from March to December 2020 and determined the characteristics of vulnerable subgroups who were at increased risk for suicide due to the pandemic.A latent class analysis of crisis support-seeking from a national text-based crisis platform, (n = 179,497, aged 24 years or younger) for 11 crisis concerns (e.g., depression, anxiety/stress, suicidal thoughts, isolation, abuse, bereavement, relationships) was performed on three study periods: (1) January 2017 to December 2020, (2) prepandemic: 1 January 2017 to 12 March 2020, and (3) pandemic: 13 March to 20 December 2020. Demographic characteristics (age, race/ethnicity, sexual orientation, and gender identity) were used as predictors for class membership using the three-step method.Four latent classes were identified: (1) depression/isolation/self-harm (D/I/S) (18,694 texters, 10.4%), (2) interpersonal stress/mood-anxiety (I/M) (32,640 texters, 18.2%), (3) suicidal thoughts/depressed (S/D) (34,067, 19.0%), and (4) adjustment/stress (A/S) (94,096 texters, 52.4%). During the pandemic, an increase in suicidal thoughts and active rescues occurred in the D/I/S and S/D higher-risk subclasses. Characteristics of vulnerable groups in higher-risk classes since the pandemic included children, LGBTQ, American Indian, White, Black, Asian, female, and gender-nonconforming youth.Results identified a strong association with class membership in more severe risk classes during the pandemic and an increase in suicidal help-seeking, particularly among children and LGBTQ youth. Low-cost and targeted crisis text-based platforms for support-seeking in youth may be one potential safety net strategy to address the effects of the COVID-19 pandemic on mental health in youth.}, number={1}, journal={JOURNAL OF ADOLESCENT HEALTH}, author={Runkle, Jennifer D. and Yadav, Shrikanth and Michael, Kurt and Green, Shannon and Weiser, Jaclyn and Sugg, Margaret M.}, year={2022}, month={Jan}, pages={48–56} }
 @article{sugg_runkle_andersen_weiser_michael_2021, title={Crisis response among essential workers and their children during the COVID-19 pandemic}, volume={153}, ISSN={["1096-0260"]}, DOI={10.1016/j.ypmed.2021.106852}, abstractNote={Limited research has been conducted on the mental health concerns of frontline and essential workers and their children during the COVID-19 pandemic in the United States (U.S.). This study examined the association between working on the frontlines in the U.S. during the COVID-19 pandemic (March to July 2020) and personal crisis text concerns (e.g., self-harm, suicidal thoughts, anxiety/stress, and substance abuse) for frontline essential workers and the children of frontline workers. We used a novel data set from a crisis texting service, Crisis Text Line (CTL), that is widely used throughout the U.S. Generalized Estimating Equations examined the individual association between eight specific crisis types (Depression, Stress/Anxiety, Self-Harm, Suicidal Thoughts, Substance Abuse, Isolation, Relationship Issues, and Abuse) and being in frontline work or being a child of a frontline worker during the early phase of the pandemic. Using CTL concerns as a proxy for the prevalence of mental health issues, we found that children of workers, specifically the youngest demographic (13 years and under), females, and non-conforming youth had a higher risk of specific crisis events during the COVID-19 pandemic. Additionally, Hispanic children of workers reported higher rates of stress/anxiety, whereas African American children of workers had higher rates of abuse and depression. Frontline workers had a higher risk of suicidal thoughts, and the risk of crisis events was generally highest for non-binary, transgender, and male users. Increases in CTL usage among frontline workers were noted across 7–28 days after spikes in local COVID-19 cases. The research to date has focused on the mental health of frontline essential workers, but our study highlights troubling trends in psychological stress among children of these workers. Supportive interventions and mental health resources are needed not only for frontline essential workers, but for their children too.}, journal={PREVENTIVE MEDICINE}, author={Sugg, Margaret M. and Runkle, Jennifer D. and Andersen, Lauren and Weiser, Jaclyn and Michael, Kurt D.}, year={2021}, month={Dec} }
 @article{runkle_sugg_graham_hodge_march_mullendore_tove_salyers_valeika_vaughan_2021, title={Participatory COVID-19 Surveillance Tool in Rural Appalachia Real-Time Disease Monitoring and Regional Response}, volume={136}, ISSN={["1468-2877"]}, DOI={10.1177/0033354921990372}, abstractNote={Introduction Few US studies have examined the usefulness of participatory surveillance during the coronavirus disease 2019 (COVID-19) pandemic for enhancing local health response efforts, particularly in rural settings. We report on the development and implementation of an internet-based COVID-19 participatory surveillance tool in rural Appalachia. Methods A regional collaboration among public health partners culminated in the design and implementation of the COVID-19 Self-Checker, a local online symptom tracker. The tool collected data on participant demographic characteristics and health history. County residents were then invited to take part in an automated daily electronic follow-up to monitor symptom progression, assess barriers to care and testing, and collect data on COVID-19 test results and symptom resolution. Results Nearly 6500 county residents visited and 1755 residents completed the COVID-19 Self-Checker from April 30 through June 9, 2020. Of the 579 residents who reported severe or mild COVID-19 symptoms, COVID-19 symptoms were primarily reported among women (n = 408, 70.5%), adults with preexisting health conditions (n = 246, 70.5%), adults aged 18-44 (n = 301, 52.0%), and users who reported not having a health care provider (n = 131, 22.6%). Initial findings showed underrepresentation of some racial/ethnic and non–English-speaking groups. Practical Implications This low-cost internet-based platform provided a flexible means to collect participatory surveillance data on local changes in COVID-19 symptoms and adapt to guidance. Data from this tool can be used to monitor the efficacy of public health response measures at the local level in rural Appalachia. }, number={3}, journal={PUBLIC HEALTH REPORTS}, author={Runkle, Jennifer D. and Sugg, Maggie M. and Graham, Garrett and Hodge, Bryan and March, Terri and Mullendore, Jennifer and Tove, Fletcher and Salyers, Martha and Valeika, Steve and Vaughan, Ellis}, year={2021}, month={May}, pages={327–337} }
 @article{runkle_matthews_sparks_mcnicholas_sugg_2022, title={Racial and ethnic disparities in pregnancy complications and the protective role of greenspace: A retrospective birth cohort study}, volume={808}, ISSN={["1879-1026"]}, DOI={10.1016/j.scitotenv.2021.152145}, abstractNote={Greenspace may positively impact pregnancy health for racially and economically minoritized populations; few studies have examined local availability and accessibility of green/park space in reducing maternal morbidity. The objective of this retrospective birth cohort study was to examine the association between residential exposure to greenspace and adverse pregnancy health outcomes in a Southern US state characterized by high poverty and racial disparities in maternal health (2013-2017). National data from the Protected Area database - United States (PAD-US) and ParkServe estimated three publicly available and accessible residential greenspace measures-a more direct proxy than using remotely-sensed greenness indicators (e.g., normalized difference vegetation index (NDVI))-(a) percent area of greenspace (M1), (b) area of available greenspace per person (M2), (c) total population within a 10-minute walk (M3). Generalized Estimating Equations with logistic regression were used to examine the association between individual greenspace metrics and South Carolina hospital deliveries (n = 238,922 deliveries) for women with correlated maternal health outcomes for gestational hypertension (GHTN), gestational diabetes (GD), severe maternal morbidity (SMM), preeclampsia (PRE), mental disorders (MD), depressive disorders (DD), and preterm birth (PTB). Lowest compared to highest tertiles of all three metrics were associated with increased risk for MD, DD, and a monotonic increase in GD, particularly for black women. Women with the lowest access to M2 and M3 were more at risk for PRE, PTB, and MD. We observed that women in low-income, majority-black communities in the lowest versus highest tertile of M2 were more likely to experience a DD, MD, SMM, or PTB compared to primarily high-income majority-white communities. Available and accessible green/park space may present as an effective nature-based intervention to reduce maternal complications, particularly for gestational diabetes and other pregnancy health risks for which there are currently few known evidence-based primary prevention strategies.}, journal={SCIENCE OF THE TOTAL ENVIRONMENT}, author={Runkle, Jennifer D. and Matthews, Jessica L. and Sparks, Laurel and McNicholas, Leo and Sugg, Margaret M.}, year={2022}, month={Feb} }
 @article{runkle_sugg_yadav_harden_weiser_michael_2021, title={Real-Time Mental Health Crisis Response in the United States to COVID-19 Insights From a National Text-Based Platform}, ISSN={["2151-2396"]}, DOI={10.1027/0227-5910/a000826}, abstractNote={ Abstract. Background: Data are scarce on assessing the impact of the COVID-19 pandemic on young people. Aim: To examine changes in crisis text patterns in the United States during the pandemic compared to the prepandemic period. Method: Nonintrusive data from a national digital crisis texting platform were analyzed using an interrupted time series design. Poisson regression with repeated-measures examined help-seeking patterns for stress, anxiety, depression, suicidal thoughts, and other mental health concerns in the pandemic (March 13 to July 20, 2020) compared to the prepandemic period (March 13 to July 20, 2019). Results: An abrupt increase in national crisis response texts occurred during the pandemic for stress and anxiety, substance abuse, bereavement, isolation, and abuse compared to the prepandemic period. Similar trends of excess texts for isolation and abuse were reported among children (relative risk [RR]abuse: 1.16, CI: 1.03, 1.31; RRisolation: 1.15, CI: 1.09, 1.21) and adolescents (RRabuse: 1.17, CI: 1.11, 1.24; RRisolation: 1.08, CI: 1.05, 1.11), bereavement among Black (RR: 1.31, CI: 1.12, 1.54) and Hispanic (RR: 1.28, CI: 1.10, 1.49) texters, and isolation and bereavement in female (RRisolation: 1.09, CI: 1.06, 1.11; RRbereavement: 1.21, CI: 1.13, 1.28) or nonconforming youth (RRisolation: 1.19, CI: 1.08, 1.32; RRbereavement: 1.50, CI: 1.08, 2.09) texters. Conversely, the risks of reporting bullying, depression, relationship issues, and suicidal thoughts as reasons for texting were significantly lower during COVID-19. Limitations: Results may underestimate crisis support-seeking in some groups because demographic data were not captured on all texters. Conclusion: Findings illuminated the real-time crisis response of young people across the United States and can inform more responsive interventions to alleviate the mental health consequences brought on by the COVID-19 pandemic. }, journal={CRISIS-THE JOURNAL OF CRISIS INTERVENTION AND SUICIDE PREVENTION}, author={Runkle, Jennifer D. and Sugg, Margaret M. and Yadav, Shrikanth and Harden, Stella and Weiser, Jaclyn and Michael, Kurt}, year={2021}, month={Oct} }
 @article{harden_runkle_weiser_green_sugg_2021, title={Spatial Clustering of Adolescent Bereavement in the United States During the COVID-19 Pandemic}, volume={69}, ISSN={["1879-1972"]}, DOI={10.1016/j.jadohealth.2021.04.035}, abstractNote={Few studies have examined grief and bereavement in the context of a pandemic, particularly among young people during the ongoing COVID-19 pandemic.The objective of this study is to examine spatiotemporal clustering of bereavement using data from Crisis Text Line, an SMS-based intervention with widespread usage among youth and adolescents in the United States from January 2017 to September 2020.Results found significant spatial clustering of bereavement during the pandemic period in the late summer months compared with the onset of the pandemic.Our study provides the first evidence of elevated bereavement in adolescents using a technique for rapidly identifying clusters of bereavement risk among this vulnerable subgroup. Findings can be leveraged for targeted interventions and supportive counseling in geographic hotspots.}, number={1}, journal={JOURNAL OF ADOLESCENT HEALTH}, author={Harden, Stella R. and Runkle, Jennifer D. and Weiser, Jaclyn and Green, Shannon and Sugg, Margaret M.}, year={2021}, month={Jul}, pages={140–143} }
 @misc{hass_runkle_sugg_2021, title={The driving influences of human perception to extreme heat: A scoping review}, volume={197}, ISSN={["1096-0953"]}, DOI={10.1016/j.envres.2021.111173}, abstractNote={Prior research demonstrates a link between heat risk perception and population response to a heat warning. Communicating a precise and understandable definition of “heat” or “heatwaves” can affect how a population perceives and responds to extreme heat. Still, little is known about how heat perception affects behavior changes to heat and heat communication across diverse populations. This scoping review aims to identify and describe the main themes and findings of recent heat perception research globally and map critical research gaps and priorities for future studies. Results revealed risk perception influences a person's exposure to and behavioral response to excessive heat. Risk perception varied geographically along the rural-urban continuum and was typically higher among vulnerable subgroups, including populations who were low-income, minority, and in poor health. A more integrated approach to refining risk communication strategies that result in a behavioral change and incorporates the individual, social, and cultural components of impactful group-based or community-wide interventions is needed. Research employing longitudinal or quasi-experimental designs and advanced statistical techniques are required to tease apart the independent and interacting factors that causally influence risk communication, heat perception, and adaptive behaviors. We advance a framework to conceptualize the structural, environmental, personal, and social drivers of population heat risk perception and how they interact to influence heat perception and adaptive behaviors. Our findings map future research priorities needed for heat perception and a framework to drive future research design.}, journal={ENVIRONMENTAL RESEARCH}, author={Hass, Alisa L. and Runkle, Jennifer D. and Sugg, Margaret M.}, year={2021}, month={Jun} }
 @article{sugg_runkle_hajnos_green_michael_2022, title={Understanding the concurrent risk of mental health and dangerous wildfire events in the COVID-19 pandemic}, volume={806}, ISSN={["1879-1026"]}, DOI={10.1016/j.scitotenv.2021.150391}, abstractNote={Little research has examined the mental health risks of concurrent disasters. For example, disasters like wildfires have been shown to have a strong association with psychological symptoms-the 2020 U.S. Western wildfire season was the worst on record and occurred while the country was still navigating the COVID-19 pandemic. We implemented two quasi-experimental analyses, an interrupted time series analysis, and a difference-in-difference analysis to evaluate the impacts of wildfires and COVID-19 on mental health crisis help-seeking patterns. Both methods showed no statistical association between exposure to wildfires and the seeking of mental health support during the COVID-19 pandemic. Results highlighted that 2020 wildfires were not associated with an acute increase in crisis texts for youth in the two months after the events, likely due to an already elevated text volume in response to the COVID-19 pandemic from March 2020 throughout the fall wildfire season (Aug to Oct 2020). Future research is needed outside of the context of the pandemic to understand the effects of extreme and concurrent climatic events on adolescent mental health, and targeted interventions are required to ensure youth and adolescents are receiving adequate support during these types of crisis events.}, journal={SCIENCE OF THE TOTAL ENVIRONMENT}, author={Sugg, Margaret M. and Runkle, Jennifer D. and Hajnos, Sarah N. and Green, Shannon and Michael, Kurt D.}, year={2022}, month={Feb} }
 @misc{sugg_runkle_leeper_bagli_golden_handwerger_magee_moreno_reed-kelly_taylor_et al._2020, title={A scoping review of drought impacts on health and society in North America}, volume={162}, ISSN={["1573-1480"]}, DOI={10.1007/s10584-020-02848-6}, abstractNote={Drought is a highly destructive natural hazard with wide-ranging impacts on water security, agriculture, energy, and human health. Unlike most natural hazards, droughts can develop anywhere, evolve rapidly within a month or slowly over a season, and span months to decades without a clear beginning or end. Few studies investigate the direct link between drought and drought-related impacts on health and society, and little research has identified critical science gaps in the field of drought-society. This scoping review aims to explore the societal implications of drought and identify knowledge gaps for future drought-society studies. We performed a PRISMA scoping review with a four-element search model on articles published since 2010. We extracted drought impacts data from 74 articles. Results were synthesized into three main topical areas examining public health impacts, water quality impacts, and water quantity impacts. While studies were heterogeneous in terms of objectives and methods, they illustrated the full breadth of drought impacts. The current body of evidence lacks a standard set of drought indices that can be readily applied to evaluate and monitor societal impacts due to drought. The challenge of defining drought limits a holistic understanding of drought effects and recovery time. More interdisciplinary collaborations are needed to establishes community-wide consensus on the identification of relevant hydrological indicators that best describe an adverse outcome is an understudied research priority.}, number={3}, journal={CLIMATIC CHANGE}, author={Sugg, Margaret and Runkle, Jennifer and Leeper, Ronnie and Bagli, Hannah and Golden, Andrew and Handwerger, Leah Hart and Magee, Tatiana and Moreno, Camila and Reed-Kelly, Rhiannon and Taylor, Michelle and et al.}, year={2020}, month={Oct}, pages={1177–1195} }
 @article{andersen_harden_sugg_runkle_lundquist_2021, title={Analyzing the spatial determinants of local Covid-19 transmission in the United States}, volume={754}, ISSN={["1879-1026"]}, DOI={10.1016/j.scitotenv.2020.142396}, abstractNote={The Coronavirus Disease 19 (COVID-19) has quickly spread across the United States (U.S.) since community transmission was first identified in January 2020. While a number of studies have examined individual-level risk factors for COVID-19, few studies have examined geographic hotspots and community drivers associated with spatial patterns in local transmission. The objective of the study is to understand the spatial determinants of the pandemic in counties across the U.S. by comparing socioeconomic variables to case and death data from January 22nd to June 30th 2020. A cluster analysis was performed to examine areas of high-risk, followed by a three-stage regression to examine contextual factors associated with elevated risk patterns for morbidity and mortality. The factors associated with community-level vulnerability included age, disability, language, race, occupation, and urban status. We recommend that cluster detection and spatial analysis be included in population-based surveillance strategies to better inform early case detection and prioritize healthcare resources.}, journal={SCIENCE OF THE TOTAL ENVIRONMENT}, author={Andersen, Lauren M. and Harden, Stella R. and Sugg, Margaret M. and Runkle, Jennifer D. and Lundquist, Taylor E.}, year={2021}, month={Feb} }
 @article{sugg_spaulding_lane_runkle_harden_hege_iyer_2021, title={Mapping community-level determinants of COVID-19 transmission in nursing homes: A multi-scale approach}, volume={752}, ISSN={["1879-1026"]}, DOI={10.1016/j.scitotenv.2020.141946}, abstractNote={Deaths from the COVID-19 pandemic have disproportionately affected older adults and residents in nursing homes. Although emerging research has identified place-based risk factors for the general population, little research has been conducted for nursing home populations. This GIS-based spatial modeling study aimed to determine the association between nursing home-level metrics and county-level, place-based variables with COVID-19 confirmed cases in nursing homes across the United States. A cross-sectional research design linked data from Centers for Medicare & Medicaid Services, American Community Survey, the 2010 Census, and COVID-19 cases among the general population and nursing homes. Spatial cluster analysis identified specific regions with statistically higher COVID-19 cases and deaths among residents. Multivariate analysis identified risk factors at the nursing home level including, total count of fines, total staffing levels, and LPN staffing levels. County-level or place-based factors like per-capita income, average household size, population density, and minority composition were significant predictors of COVID-19 cases in the nursing home. These results provide a framework for examining further COVID-19 cases in nursing homes and highlight the need to include other community-level variables when considering risk of COVID-19 transmission and outbreaks in nursing homes.}, journal={SCIENCE OF THE TOTAL ENVIRONMENT}, author={Sugg, Margaret M. and Spaulding, Trent J. and Lane, Sandi J. and Runkle, Jennifer D. and Harden, Stella R. and Hege, Adam and Iyer, Lakshmi S.}, year={2021}, month={Jan} }
 @article{runkle_michael_stevens_sugg_2021, title={Quasi-experimental evaluation of text-based crisis patterns in youth following Hurricane Florence in the Carolinas, 2018}, volume={750}, ISSN={["1879-1026"]}, DOI={10.1016/j.scitotenv.2020.141702}, abstractNote={Crisis text lines have proven to be an effective and low-cost means for delivering texting-based mental health support to youth. Yet there has been limited research examining the use of these services in capturing the psychological impact on youth affected by a weather-related disaster. This ecologic study examined changes in help-seeking behavior for adolescents and young adults in North and South Carolina, USA, before and after Hurricane Florence (2018). A retrospective, interrupted time-series design was used to examine pre- and post-hurricane changes in crisis text volume among youth help seekers in the Carolinas for the following outcomes: (1) text for any reason; (2) stress & anxiety; (3) depression; and (4) suicidal thoughts. Results showed an immediate and sustained increase in crisis texts for stress/anxiety and suicidal thoughts in the six weeks following Florence. Overall, an immediate 15% increase in crisis texts for anxiety/stress (SE = 0.05, p = .005) and a 17% increase in suicidal thoughts (SE = 0.07, p = .02) occurred during the week of the storm. Text volume for anxiety/stress increased 17% (SE = 0.08, p = .005) and 23% for suicidal ideation (SE = 0.08, p = .01) in the 6-week post-hurricane period. Finally, forecast models revealed observed text volume for all mental health outcomes was higher than expected in the 6 weeks post-Florence. A low-cost, crisis texting platform provided 24/7 mental health support available to young people in the Carolinas impacted by Hurricane Florence. These findings highlight a new application for text-based crisis support services to address the mental health consequences in youth following a weather-related disaster, as well as the potential for these types of crisis platforms to measure situational awareness in impacted communities.}, journal={SCIENCE OF THE TOTAL ENVIRONMENT}, author={Runkle, Jennifer D. and Michael, Kurt D. and Stevens, Scott E. and Sugg, Margaret M.}, year={2021}, month={Jan} }
 @article{nelson_runkle_sugg_2020, title={Reporting Back Environmental Health Data Among Outdoor Occupational Workers in the Cold Season in North Carolina, USA}, volume={60}, ISSN={["1549-6929"]}, DOI={10.1353/sgo.2020.0013}, abstractNote={abstract:Reporting data back to study participants provides important environmental health literacy opportunities to mitigate dangerous temperature extremes. Our study centers an occupationally exposed population who are vulnerable to cold-related illness and injury and aims to understand the response to their personal biometeorological monitoring data in the cold season. Geo-referenced data were collected from wearable sensors that measured temperature and heart rate information from January 22 to February 9, 2018 at two separate study sites in North Carolina (n = 66). At the end of data collection, biomonitoring results were given to participants in the form of a report-back packet that displayed results in multiple formats, including maps and tables. A survey was conducted to assess potential behavioral modifications and preferences of health data formatting (n = 47). Our study found that 94 percent (n = 44) of workers thought that the report-back itself was personally useful, and 98 percent (n = 45) believed that the monitoring results well-represented one’s own cold exposure status. In addition, after receiving their individual results, workers expressed a greater willingness to change their behaviors at work to reduce their cold exposure. Results suggest that reporting biomonitoring studies to urban and rural occupationally exposed populations is an effective means to promote behavioral change to cold temperature vulnerability.}, number={2}, journal={SOUTHEASTERN GEOGRAPHER}, author={Nelson, Kimberly B. and Runkle, Jennifer D. and Sugg, Margaret M.}, year={2020}, pages={159–182} }
 @article{runkle_sugg_leeper_rao_matthews_rennie_2020, title={Short-term effects of specific humidity and temperature on COVID-19 morbidity in select US cities}, volume={740}, ISSN={["1879-1026"]}, url={https://doi.org/10.1016/j.scitotenv.2020.140093}, DOI={10.1016/j.scitotenv.2020.140093}, abstractNote={Little is known about the environmental conditions that drive the spatiotemporal patterns of SARS-CoV-2. Preliminary research suggests an association with meteorological parameters. However, the relationship with temperature and humidity is not yet apparent for COVID-19 cases in US cities first impacted. The objective of this study is to evaluate the association between COVID-19 cases and meteorological parameters in select US cities. A case-crossover design with a distributed lag nonlinear model was used to evaluate the contribution of ambient temperature and specific humidity on COVID-19 cases in select US cities. The case-crossover examines each COVID case as its own control at different time periods (before and after transmission occurred). We modeled the effect of temperature and humidity on COVID-19 transmission using a lag period of 7 days. A subset of 8 cities were evaluated for the relationship with meteorological parameters and 5 cities were evaluated in detail. Short-term exposure to humidity was positively associated with COVID-19 transmission in 4 cities. The associations were small with 3 out of 4 cities exhibiting higher COVID19 transmission with specific humidity that ranged from 6 to 9 g/kg. Our results suggest that weather should be considered in infectious disease modeling efforts. Future work is needed over a longer time period and across different locations to clearly establish the weather-COVID19 relationship.}, journal={SCIENCE OF THE TOTAL ENVIRONMENT}, publisher={Elsevier BV}, author={Runkle, Jennifer D. and Sugg, Margaret M. and Leeper, Ronald D. and Rao, Yuhan and Matthews, Jessica L. and Rennie, Jared J.}, year={2020}, month={Oct} }
 @article{sugg_woolard_lawrimore_michael_runkle_2021, title={Spatial Clustering of Suicides and Neighborhood Determinants in North Carolina, 2000 to 2017}, volume={14}, ISSN={["1874-4621"]}, DOI={10.1007/s12061-020-09364-1}, number={2}, journal={APPLIED SPATIAL ANALYSIS AND POLICY}, author={Sugg, Margaret M. and Woolard, Sarah and Lawrimore, Margaret and Michael, Kurt D. and Runkle, Jennifer D.}, year={2021}, month={Jun}, pages={395–413} }
 @article{sugg_dixon_runkle_2019, title={Crisis support-seeking behavior and temperature in the United States: Is there an association in young adults and adolescents?}, volume={669}, ISSN={["1879-1026"]}, DOI={10.1016/j.scitotenv.2019.02.434}, abstractNote={Mounting evidence demonstrates the relationship between high temperatures and adverse mental health outcomes. Yet, no study has examined the influence of temperature on crisis support-seeking behavior among youth in large urban areas. Crisis Text Line (CTL) is a text messaging service that provides crisis interventions for support-seeking individuals for a range of mental-health outcomes in the United States. We applied a distributed lag non-linear modeling technique to assess the short-term impacts of daily maximum and minimum temperature on crisis-related events in four metropolitan locations in the USA. There were multiple positive associations in three of the four study locations that demonstrate crisis help-seeking behavior increased during anomalously warm conditions. This study suggests that there is a significant association between high minimum or maximum temperatures and crisis help-seeking behaviors in young adults and adolescents in urban areas in the United States.}, journal={SCIENCE OF THE TOTAL ENVIRONMENT}, author={Sugg, Margaret M. and Dixon, P. Grady and Runkle, Jennifer D.}, year={2019}, month={Jun}, pages={400–411} }
 @article{sugg_stevens_runkle_2019, title={Estimating personal ambient temperature in moderately cold environments for occupationally exposed populations}, volume={173}, ISSN={["1096-0953"]}, DOI={10.1016/j.envres.2019.03.066}, abstractNote={Despite high mortality and morbidity rates in the winter season, few studies have investigated the health effects from working in moderately cold environments, especially among vulnerable outdoor worker populations in the southeastern US. Yet recent research has shown that the mortality risk from cold events is greatest in southern cities compared to other US locations. We performed repeated personal cold exposure measurements in outdoor grounds management workers in the southeastern US using consumer-based sensors. We recruited outdoor workers from two locations (Raleigh, NC and Boone, NC) each characterized by climatological differences in cold temperature to participate in a 3-week data collection period at the peak of the winter (Jan/Feb 2018). Lower personal ambient temperatures were observed among participants who worked in a warmer climate (Raleigh, NC). The relative risk for cold symptomatology was higher in moderately cold personal ambient temperatures (0 °C to 20 °C) than extremely cold personal ambient temperatures (less than 0 °C). A weak significant relationship was observed between personal ambient temperatures and weather station measurements highlighting that epidemiological researchers should be cautious when investigating the health effects of ambient temperatures based on fixed site measurements. As mobile technology progresses, real-time temperature health monitoring and analysis of environmental conditions at the individual level across multiple occupational-settings will become more feasible and ultimately, we believe, a digitally enhanced workforce will become standard practice in the field.}, journal={ENVIRONMENTAL RESEARCH}, author={Sugg, Margaret M. and Stevens, Scott and Runkle, Jennifer D.}, year={2019}, month={Jun}, pages={497–507} }
 @article{runkle_cui_fuhrmann_stevens_del pinal_sugg_2019, title={Evaluation of wearable sensors for physiologic monitoring of individually experienced temperatures in outdoor workers in southeastern US}, volume={129}, ISSN={["1873-6750"]}, DOI={10.1016/j.envint.2019.05.026}, abstractNote={Climate-related increases in global mean temperature and the intensification of heat waves present a significant threat to outdoor workers. Limited research has been completed to assess the potential differences in heat exposures that exist between individuals within similar microenvironments. Yet, there is a paucity of individual data characterizing patterns of individually experienced temperatures in workers and the associated physiologic heat strain response. The objective of this study was to apply a wearable sensor-based approach to examine the occupational, environmental, and behavioral factors that contribute to individual-level variations in heat strain in grounds maintenance workers. Outdoor workers from three diverse climatic locations in the southeastern United States – high temperature, high temperature + high humidity, and moderate temperature environments – participated in personal heat exposure monitoring during a 5-day work period in the summer. We performed Cox proportional hazards modeling to estimate associations between multiple heat strain events per worker and changes in individually experienced temperatures. Heat strain risk was higher among workers with a place to cool-off, higher education, and who worked in hotter temperatures. A mismatch was observed between workers' perceptions of heat strain and actual heat strain prevalence across exposure groups. We also used a quasi-Poisson regression with distributed lag non-linear function to estimate the non-linear and lag effects of individually experienced temperatures on risk of heat strain. The association between increasing temperature and heat strain was nonlinear and exhibited an U-shaped relationship. Heat strain was less common during issued heat warnings demonstrating behavioral adaptive actions taken by workers. This study is one of the first temperature monitoring studies to quantify the individual-level exposure-response function in this vulnerable population and highlights the elevated risk of heat strain both immediately and several days after worker exposure to high temperatures.}, journal={ENVIRONMENT INTERNATIONAL}, author={Runkle, Jennifer D. and Cui, Can and Fuhrmann, Chris and Stevens, Scott and Del Pinal, Jeff and Sugg, Margaret M.}, year={2019}, month={Aug}, pages={229–238} }
 @article{sugg_fuhrmann_runkle_2020, title={Geospatial Approaches to Measuring Personal Heat Exposure and Related Health Effects in Urban Settings}, ISBN={["978-3-030-19572-4"]}, ISSN={["2522-8013"]}, DOI={10.1007/978-3-030-19573-1_2}, abstractNote={Recent and projected changes in temperature extremes, including the intensification of heat waves, present a persistent health threat for urban residents. Due to limitations in data availability and the spatial representativeness of fixed-site temperature observations, there exists a notable gap in the geospatial sciences on the multi-scale characterization of geographic patterns of extreme heat and the associated correlation with individual vulnerability in urban settings. Studies employing individual-level exposure assessment methodologies are sparse. Yet rapid advancements in low-cost wearable sensors and other mobile technologies can be leveraged to capture geo-referenced environmental exposure (e.g., temperature) and health data (e.g., physiologic strain) to better understand and quantify the impacts of variations in individual microclimates. The emergence of new technologies and rich spatial datasets requires multi-disciplinary collaboration to advance the science on place-based exposure to thermal extremes and the associated health impacts for at-risk populations in urban environments.}, journal={GEOSPATIAL TECHNOLOGIES FOR URBAN HEALTH}, author={Sugg, Margaret M. and Fuhrmann, Christopher M. and Runkle, Jennifer D.}, year={2020}, pages={13–30} }
 @article{sugg_fuhrmann_runkle_2020, title={Perceptions and experiences of outdoor occupational workers using digital devices for geospatial biometeorological monitoring}, volume={64}, ISSN={["1432-1254"]}, DOI={10.1007/s00484-019-01833-8}, abstractNote={Wearable devices have the potential to track and monitor a wide range of biometeorological conditions (e.g., temperature, UV, air quality) and health outcomes (e.g., mental stress, physical activity, physiologic strain, and cognitive impairments). These sensors provide the potential for personalized environmental exposure information that can be harnessed for at-risk populations. Personalized environmental exposure information is of particular importance for populations that are continuously exposed to hazardous environmental conditions or with underlying health conditions. Yet, for these devices to be effective, individuals must be willing to monitor their health and, if prompted, adhere to warnings or notifications. To date, no study has examined the perceptions and use of digital devices and wearable sensors among vulnerable outdoor working populations. This study evaluated digital device use and perceptions among a population of groundworkers in three diverse geographic sites in the southeastern USA (Boone, NC, Raleigh, NC, and Starkville, MS). Our results demonstrate that biometeorological health interventions should focus on smartphone technology as a platform for monitoring environmental exposure and associated health outcomes. It was encouraging to find that those study participants were very likely to wear sensors and utilize global positioning system technology despite potential privacy issues. In addition, 3 out of 4 workers indicated that they would change their behavior if given a personalized heat preventive warning. Future development of wearable sensors and smartphone applications should integrate personalized weather warnings and ensure privacy to facilitate the use of these technologies among vulnerable populations.}, number={3}, journal={INTERNATIONAL JOURNAL OF BIOMETEOROLOGY}, author={Sugg, Margaret M. and Fuhrmann, Christopher M. and Runkle, Jennifer D.}, year={2020}, month={Mar}, pages={471–483} }
 @article{runkle_sugg_boase_galvin_coulson_2019, title={Use of wearable sensors for pregnancy health and environmental monitoring: Descriptive findings from the perspective of patients and providers}, volume={5}, ISSN={["2055-2076"]}, DOI={10.1177/2055207619828220}, abstractNote={Background Wearable sensors and other smart technology may be especially beneficial in providing remote monitoring of sub-clinical changes in pregnancy health status. Yet, limited research has examined perceptions among pregnant patients and providers in incorporating smart technology into their daily routine and clinical practice. Objective The purpose of this study was to examine the perceptions of pregnant women and their providers at a rural health clinic on the use of wearable technology to monitor health and environmental exposures during pregnancy. Methods An anonymous 21-item e-survey was administered to family medicine or obstetrics and gynecology ( n=28) providers at a rural health clinic; while a 21-item paper survey was administered to pregnant women ( n=103) attending the clinic for prenatal care. Results Smartphone and digital technology use was high among patients and providers. Patients would consider wearing a mobile sensor during pregnancy, reported no privacy concerns, and felt comfortable sharing information from these devices with their physician. About seven out of 10 women expressed willingness to change their behavior during pregnancy in response to receiving personalized recommendations from a smartphone. While most providers did not currently use smart technologies in their medical practice, about half felt it will be used more often in the future to diagnose and remotely monitor patients. Patients ranked fetal heart rate and blood pressure as their top preference for health monitoring compared to physicians who ranked blood pressure and blood glucose. Patients and providers demonstrated similar preferences for environmental monitoring, but patients as a whole expressed more interests in tracking environmental measures compared to their providers. Conclusions Patients and providers responded positively to the use of wearable sensor technology in prenatal care. More research is needed to understand what factors might motivate provider use and implementation of wearable technology to improve the delivery of prenatal care. }, journal={DIGITAL HEALTH}, author={Runkle, Jennifer and Sugg, Maggie and Boase, Danielle and Galvin, Shelley L. and Coulson, Carol C.}, year={2019}, month={Feb} }
 @article{bailey_fuhrmann_runkle_stevens_brown_sugg_2020, title={Wearable sensors for personal temperature exposure assessments: A comparative study}, volume={180}, ISSN={["1096-0953"]}, DOI={10.1016/j.envres.2019.108858}, abstractNote={The impacts of heat on human health has sparked research on different approaches to measure, map, and predict heat exposure at more accurate and precise spatiotemporal scales. Personal heat sensor studies rely on small sensors that can continuously measure ambient temperatures as individuals move through time and space. The comparison between different types of sensors and sensor placements have yet to be fully researched. The objective of this study is to assess the validity of personal ambient temperature sensors. To accomplish this objective, we evaluated the performance of multiple low-cost wearable sensors (HOBOs, iButton Thermochrons, iButton Hygrochrons, and Kestrel DROP D3FW Fire) for measuring ambient temperature in a (1) field exposure study by varying the placement on human subjects and in a (2) field calibration study by co-locating sensors with fixed site weather station monitors. A secondary aim involved investigating consensus between validation metrics that can be used in future sensor comparison studies. Bland-Altman analysis, correlation coefficients, and index of agreement statistics were used to quantify the difference between sensor and weather station ambient temperature measurements. Results demonstrated significant differences in measured temperatures for sensors based on sensor type and placement on participants. Future research should account for the differences in personal ambient temperature readings based on sensor type and placement.}, journal={ENVIRONMENTAL RESEARCH}, author={Bailey, Elizabeth and Fuhrmann, Christopher and Runkle, Jennifer and Stevens, Scott and Brown, Michael and Sugg, Margaret}, year={2020}, month={Jan} }
 @misc{runkle_flocks_economos_dunlop_2017, title={A systematic review of Mancozeb as a reproductive and developmental hazard}, volume={99}, ISSN={["1873-6750"]}, DOI={10.1016/j.envint.2016.11.006}, abstractNote={The potential adverse reproductive and developmental effects of Mancozeb, especially in sensitive subpopulations, have not been fully reviewed for this widely used fungicide. To review the experimental and epidemiologic evidence for the association between exposure to Mancozeb and reproductive and developmental health outcomes using an adaptation of the National Toxicology Program's Office of Health Assessment and Translation (OHAT) systematic review framework. Four databases (PubMed, TOXNET, Web of Science, Google Scholar) were searched for published studies on Mancozeb. Of 403 identified articles, 30 met our inclusion criteria for systematic review. Results from in vitro studies provide evidence that Mancozeb may indirectly disrupt or impair reproduction at the cellular level and should be regarded as a reproductive toxicant. Animal studies confirm reproductive and developmental toxicity in mammals and suggest that males chronically exposed to Mancozeb experience significant changes in physiological, biochemical, and pathological processes that may lead to infertility. Epidemiological studies were limited to indirect methods of exposure assessment and examined the effect of fungicides more broadly during pre-conception, pregnancy, and birth, yielding mixed results. High confidence ratings from in vitro and animal studies, in combination with moderate confidence ratings from epidemiologic studies employing indirect methods of exposure assessment, provide evidence that Mancozeb should be regarded as a suspected developmental hazard and a presumed reproductive hazard in humans. More population-based studies linking direct measures and/or biomarkers of exposure to adverse effects on male and female fertility, as well as in utero and early life development, are needed to improve the quality of the evidence base concerning the human reproductive and developmental consequences of Mancozeb exposure.}, journal={ENVIRONMENT INTERNATIONAL}, author={Runkle, Jennifer and Flocks, Joan and Economos, Jeannie and Dunlop, Anne L.}, year={2017}, month={Feb}, pages={29–42} }