Abstract
Background
This study explored associations between social and built environmental factors and leisure-time physical activity (LTPA) in rural cancer survivors (RCS) and whether these associations differed by exercise stage of change (SOC).
Method
RCS (n = 219) completed questionnaires assessing LTPA, SOC, and social (social status, connectedness, support) and environmental (home environment, neighborhood environment) factors. Linear regression models examined associations between social and built environmental factors and LTPA and tested for moderation by SOC.
Results
Half (50.7%) of RCS were physically active, and 49.3% were not active. Social factors positively associated with LTPA included subjective social status in the community (B = 89.0, P = .014) and in the United States (B = 181.3, P < .001), social connectedness (B = 122.3, P = .024), and social support for physical activity from family (B = 41.9, P < .001) and friends (B = 44.3, P < .001). Environmental factors positively associated with LTPA included the home environment (B = 111.2, P < .001), perceived environmental support for PA (B = 355.4, P = .004), and neighborhood attributes, including bicycling infrastructure (B = 191.3, P = .003), proximity to recreation facilities (B = 140.1, P = .021), traffic safety (B = 184.5, P = .025), and aesthetics (B = 342.6, P < .001). SOC statistically significantly moderated the association between social status in the United States and LTPA (B = 160.3, P = .031).
Conclusions
Social and built environmental factors were consistently linked with LTPA and provide context for multilevel interventions promoting LTPA in RCS.
Physical activity (PA) reduces the risk of cancer mortality and recurrence and the amount and severity of treatment-related adverse effects (1,2). PA is generally safe for most cancer survivors, and cancer survivors should avoid inactivity (1). However, only 14.2% of cancer survivors meet PA guidelines (3), and more than half of all adult cancer survivors in the United States report no leisure-time PA (LTPA) (4). LTPA includes discretionary activities that are performed outside of one’s job and in addition to activities performed in the home or yard (eg, laundry, gardening) and for transportation (eg, walking or cycling to work or the bus stop). Although the PA guidelines for cancer survivors frame recommendations in terms of total accumulated moderate-vigorous PA, mounting evidence suggests LTPA may be most critical for driving health outcomes (5-7).
Physical inactivity is especially high among cancer survivors residing in rural areas (8,9). Rural-urban differences in LTPA are also observed in the general population (10) but to a lesser extent than the observed discrepancy in LTPA between urban and rural cancer survivors. One study found cancer survivors living in urban areas were more than twice as likely than those in rural areas to meet PA recommendations (8). Although the reasons for differences in LTPA between rural and urban cancer survivors are not well understood, previous research suggests that multilevel determinants, including social and built environmental factors, may contribute to rural-urban differences and warrant additional research (11,12).
Socio-ecological models (SEMs) provide a multilevel framework to explain how health behaviors and outcomes are impacted by the interrelationships between individuals and their social and environmental contexts (13). The Ecological Model of Four Domains of Active Living is an example of a behavior-specific SEM (14). According to the socio-ecological model for leisure-time physical activity behavior (Figure 1), differences in PA between rural and urban populations may be related to how rural and urban areas provide different lived experiences in terms of social interactions and environmental characteristics (15). For example, rural cancer survivors may interact with a smaller network of peers on a daily basis. Moreover, in rural areas, there may be fewer recreation facilities available locally, available facilities may offer fewer resources or services (eg, limited equipment, classes), or facilities may require extensive travel by car or public transportation. Although less traffic in rural areas might suggest increased safety while engaging in outdoor PA, a lack of sidewalks or an abundance of roads in need of maintenance might discourage individuals from walking or choosing active transportation as often as their urban counterparts.
Figure 1.
A behavior-specific socio-ecological model for leisure-time physical activity behavior. Adapted from the Ecological Model of Four Domains of Active Living.14
From a socio-ecologic perspective, the relationships between social and built environmental factors and LTPA among rural cancer survivors may differ because of varying individual characteristics, such as an individual’s exercise stage of change. Exercise stage of change measures an individual’s motivational readiness to engage in a new behavior and suggests that individuals move in an orderly progression through stages: precontemplation, contemplation, preparation, action, or maintenance stages of change (16). If a cancer survivor is in the precontemplation, contemplation, or preparation stage of change, they may or may not be considering becoming active but are currently not physically active. In contrast, if someone is in the action or maintenance stages, then we can assume they are regularly physically active. Because exercise stage of change is dynamic, it can be used to capture an individual’s intentions and perceptions of behavior and tailor intervention strategies to one’s current PA habits (16).
Low LTPA among rural cancer survivors renders this population at high risk for long-term treatment-related morbidity and early mortality in the survivorship period (17). Thus, mitigating this modifiable risk factor is critical to promoting long-term health in this population. This study addresses knowledge gaps regarding how multilevel socio-ecological factors support or hinder LTPA in rural cancer survivors. Specifically, we aimed to identify critical associations between perceived aspects of the social and built environments and LTPA among a sample of rural cancer survivors. Additionally, we explored whether associations between aspects of the social and built environment and LTPA in rural cancer survivors differed by exercise stage of change. We hypothesized that greater social status, social connectedness, and social support would be associated with greater LTPA and that the home environment and attributes of the neighborhood environment (eg, infrastructure, proximity to facilities, perceived safety) would be associated with greater LTPA.
Methods
Study design
Data were analyzed from the Partnering to Prevent and Control Cancer (PPCC) study, a cross-sectional study that examined multilevel determinants of PA adoption and maintenance among cancer survivors living in rural areas in central Pennsylvania. The PPCC study was reviewed and approved by the institutional review boards at the Pennsylvania State University and The University of Texas MD Anderson Cancer Center, and informed consent was provided prior to participation. PPCC study details have been published previously and are described briefly below (18-20).
Participants and procedures
Cancer survivors identified as residing in a rural county in Pennsylvania were recruited to the study, as described previously. Eligible participants were aged 18 years or older, had received a cancer diagnosis, lived primarily within a 28-county area in central Pennsylvania, and were able to read and complete questionnaires in English. Participants who returned a brief questionnaire to enroll in the study were mailed an in-depth questionnaire to assess their PA and social and environmental determinants of PA. Of the 263 participants who completed the brief questionnaire, 219 (83.3%) returned the in-depth questionnaire and were included in the present study. There were no statistically significant differences in demographic characteristics between those who returned the in-depth questionnaire and those who did not and were excluded from this study.
Measures
The primary outcome, LTPA, was assessed using the International Physical Activity Questionnaire long form (21), which has been widely used in diverse samples and is a valid and reliable tool to assess PA (22,23).
Social environment factors included subjective social status, social connectedness, perceived social support, and social support for PA from family and friends. The MacArthur Scale of Subjective Social Status is a valid and reliable instrument to assess subjective social status (24,25). Participants were asked to select from a 10-rung ladder the rung that best represents where they stand relative to others in their community and in the United States. Scores ranged from 1 to 10, with higher scores indicating higher subjective social status. Social connectedness was measured using the Berkman-Syme Social Network Index (26), which assesses the type, size, closeness, and frequency of contacts in one’s current social network. Scores range from 0 to 4, with higher scores indicating greater social connectedness. The 12-item Interpersonal Support Evaluation List–12 was used to assess overall perceived social support (27), which ranges from 0 to 36, with a higher score indicating greater perceived social support. We also assessed social support for PA using the Social Support and Exercise scale, which includes 10 items on support for PA from family and friends (28). Scores ranged from 10 to 50, with higher scores indicating higher social support for PA.
Built environment factors included the home environment and perceived neighborhood environment. The home environment for PA was assessed using the Home Environment scale (29). Participants were asked to self-report PA equipment in their home from a 15-item list. The total number of items was used in analyses. The Physical Activity Neighborhood Environment Survey (PANES) was used to measure participants’ perceptions of their neighborhood environment, which was defined as the area within a 10- to 15-minute walk from their home (30). The PANES includes 17 items to assess perceptions of the neighborhood environment for walking and cycling, and items are categorized into the following constructs: land use mix, transit access, pedestrian infrastructure, bicycling infrastructure, proximity to recreational facilities, street connectivity, crime safety, traffic safety, pedestrian safety, and aesthetic qualities. The PANES has been shown to have high reliability and validity with respective environmental attributes for PA (31,32). Both the overall mean PANES score and scores for individual constructs were included in analyses. Scores ranged from 1 to 4, with higher scores indicating greater environmental support for PA.
Exercise stage of change was assessed using the Exercise Stage of Change (short form), a single item to assess whether participants exercise regularly and for how long, if applicable (16). Participants were provided a definition of regular exercise and asked whether they exercise regularly according to that definition. Based on whether they are exercising regularly according to the definition provided and the length of time they have been engaging in the behavior, participants were categorized as being in the precontemplation, contemplation, preparation, action, or maintenance stage of change. For analyses, participants in the precontemplation, contemplation, or preparation stages were grouped as “not regularly physically active,” and those in the action or maintenance stages were grouped as “regularly physically active.”
Statistical analysis
Summary statistics (eg, means and standard deviations) were used to describe continuous variables, and frequencies, and percentages were used to describe categorical variables.
Pearson correlations were used to explore associations between social and environmental variables, exercise stage of change, and LTPA, and bivariate linear regression models were used to estimate the effect of social and environmental variables on LTPA. Ordinary least squares regression was used to explore 2-way interactions between social and environmental variables and exercise stage of change to test whether exercise stage of change moderated the association between social and environmental variables and LTPA. The dependent variable was continuous LTPA, and independent variables included continuous measures of social environment constructs (subjective social status in the community and United States, social connectedness, perceived social support, and social support from family and friends) and built environment constructs (home environment, overall perceived environment, and 10 neighborhood environment attributes). The moderator was exercise stage of change, which was dichotomized and defined as “not regularly active” (scored 1 to 3) vs “regularly active” (scored 4 or 5). In total, 18 models were run to explore the moderating effect of exercise stage of change with each social and built environment construct, and a statistically significant interaction term indicated a potential moderating effect of exercise stage of change on LTPA. Analyses were performed using Stata/SE 16.1 (StataCorp 2019, Stata Statistical Software: Release 16, StataCorp LLC, College Station, TX, USA), and a P value of .05 was used as the cutoff for statistical significance.
Results
Cancer survivors (n = 219) were mostly women (60.7%) aged in their mid-60s (mean age = 64.5 [12.2] years) and reported relatively high socioeconomic status (50.5% completed college and 80.5% reported an annual household income ≥$40 000). Most participants were breast (30.6%) or prostate (27.4%) cancer survivors, and 90.4% were at least 12 weeks but less than 5 years posttreatment. Demographic characteristics of participants are shown in Table 1.
Table 1.
Participant characteristics (n = 219)
| Characteristic | No. (%) | |
|---|---|---|
| Age, mean (SD), y | 64.5 (12.2) | |
| Body mass index, mean (SD), kg/m2 | 29.6 (6.9) | |
| Female | 133 (60.7) | |
| Non-Hispanic White | 212 (96.8) | |
| Education | ||
| <Bachelor degree | 108 (49.5) | |
| 4-year bachelor degree or more | 110 (50.5) | |
| Annual income | ||
| <$40 000 | 40 (19.4) | |
| $40 000-79 999 | 66 (32.0) | |
| ≥$80 000 | 100 (48.5) | |
| Cancer type | ||
| Breast | 67 (30.6) | |
| Colorectal | 29 (13.2) | |
| Gynecological | 48 (21.9) | |
| Lung | 20 (9.1) | |
| Prostate | 60 (27.4) | |
| Time since treatment | ||
| Currently receiving or planning to receive treatment | 21 (9.7) | |
| At least 12 weeks | 196 (92.5) | |
| More than 5 years | 19 (9.2) | |
Table 2 summarizes outcomes used in analyses, including LTPA, exercise stage of change, subjective social status, social connectedness, perceived overall social support and social support for PA, home environment for exercise, and perceived neighborhood environment. More than half of participants were in the action (12.4%) or maintenance (38.3%) stage of change for exercise and classified as regularly active compared with 21.1% in precontemplation, 18.2% in contemplation, and 10.0% in preparation and classified as not regularly active.
Table 2.
Mean (SD) leisure-time physical activity, exercise stage of change, and social and environmental factorsa
| Measure | M (SD) | |
|---|---|---|
| IPAQ leisure-time physical activity (MET-minutes per week) | 739.8 (1227.5) | |
| Exercise stage of change (scale: 1-5) | 3.3 (1.6) | |
| Subjective social status (scale: 1-10) | ||
| In the community | 6.2 (2.0) | |
| In the United States | 6.3 (1.8) | |
| Social connectedness (scale: 1-4) | 3.2 (1.4) | |
| Overall perceived social support (scale: 0-36) | 24.5 (5.0) | |
| Social support for physical activity | ||
| From family | 18.4 (8.3) | |
| From friends | 15.5 (7.8) | |
| Home environment (scale: 0-15) | 4.0 (2.6) | |
| Perceived neighborhood environment (scale: 1-4) | 2. 7 (0.6) | |
| Land use mix | 1.8 (0.9) | |
| Transit access | 2.0 (1.3) | |
| Pedestrian infrastructure | 2.2 (1.3) | |
| Bicycling infrastructure | 2.2 (1.2) | |
| Proximity to recreational facilities | 2.4 (1.2) | |
| Street connectivity | 2.2 (1.2) | |
| Crime safety | 3.7 (0.6) | |
| Traffic safety | 3.3 (0.9) | |
| Pedestrian safety | 2.9 (1.0) | |
| Aesthetic qualities | 3.0 (0.9) | |
MET = metabolic equivalent of task; IPAQ = International Physical Activity Questionnaire.
Exercise stage of change was statistically significantly positively correlated with LTPA (r = 0.48, P < .001), subjective social status in the community (r = 0.26, P < .001) and United States (r = 0.34, P < .001), social connectedness (r = 0.27, P < .001), overall perceived social support (r = 0.18, P = .009), social support for PA from family (r = 0.36, P < .001) and friends (r = 0.27, P < .001), the home environment for exercise (r = 0.36, P < .001), and overall perceived neighborhood environment (r = 0.20, P = .005). Exercise stage of change was also statistically significantly positively correlated with neighborhood environment attributes, including the bicycling infrastructure (r = 0.19, P = .008), proximity to recreation facilities (r = 0.15, P = .035), pedestrian safety (r = 0.15, P = .030), and aesthetic qualities (r = 0.36, P < .001). Statistically significant correlations between exercise stage of change, social environment characteristics, and built environment characteristics ranged from weak (r = 0.15) to moderate (r = 0.48).
Results from linear regression models assessing associations between social and built environment characteristics and LTPA are presented in Table 3. Within the social environment, linear regression models showed that greater subjective social status in the community and in the United States, greater social connectedness, and greater social support for PA from family and friends were statistically significantly associated with greater LTPA. Within the built environment, more equipment in the home and overall greater perceived environmental support for PA were statistically significantly associated with greater LTPA. Individual neighborhood attributes associated with greater PA included bicycling infrastructure, proximity to recreation facilities, traffic safety, and aesthetic qualities.
Table 3.
Associations between social and built environment characteristics and leisure-time physical activitya
| Characteristic | B | SE | t | P |
|---|---|---|---|---|
| Subjective social status | ||||
| In the community | 89.0 | 35.9 | 2.5 | .014 |
| In the United States | 181.3 | 37.4 | 4.9 | <.001 |
| Social connectedness | 122.3 | 53.8 | 2.3 | .024 |
| Overall perceived social support | 5.2 | 14.4 | 0.4 | .721 |
| Social support for physical activity | ||||
| From family | 41.9 | 8.2 | 5.1 | <.001 |
| From friends | 44.3 | 8.6 | 5.1 | <.001 |
| Home environment | 111.2 | 26.4 | 4.2 | <.001 |
| Perceived neighborhood environment | 355.4 | 120.4 | 3.0 | .004 |
| Land use mix | 109.2 | 77.3 | 1.4 | .159 |
| Transit access | 36.3 | 59.5 | 0.6 | .543 |
| Pedestrian infrastructure | 90.1 | 58.5 | 1.5 | .125 |
| Bicycling infrastructure | 191.3 | 63.5 | 3.0 | .003 |
| Proximity to recreational facilities | 140.1 | 60.1 | 2.3 | .021 |
| Street connectivity | −47.9 | 61.7 | −0.8 | .438 |
| Crime safety | 152.8 | 130.7 | 1.2 | .244 |
| Traffic safety | 184.5 | 81.8 | 2.3 | .025 |
| Pedestrian safety | 14.9 | 73.4 | 0.2 | .840 |
| Aesthetic qualities | 342.6 | 80.8 | 4.2 | <.001 |
Unstandardized beta values (B), standard errors (SE), t statistics (t), and P values reported. Bold font denotes statistically significant findings (P < .05).
Ordinary least squares regression models including interaction terms showed main effects of exercise stage of change on LTPA (Supplementary Table 1, available online), and exercise stage of change statistically significantly moderated the association between subjective social status in the United States and LTPA (B = 160.3, SE = 73.8, 95% confidence interval = 2.3 to 91.2). There was a stronger positive association between subjective social status in the United States and LTPA for participants who were regularly active compared with those who were not regularly active (Figure 2). There was no other evidence that exercise stage of change moderated the association between any other social or built environment factor and LTPA.
Figure 2.
Interaction between perceived social status in the United States and exercise stage of change on rural cancer survivors’ leisure-time physical activity in the last 7 days. CI = confidence interval; ECS = Exercise Stage of Change; MET = metabolic equivalent of task.
Discussion
This cross-sectional study examined associations between social and built environment factors and LTPA and tested exercise stage of change as a moderator in a sample of rural cancer survivors. The results of this study are consistent with a socio-ecological perspective of PA (14). Although nearly all the social and built environmental factors measured showed consistent positive associations with LTPA, the strongest associations in magnitude were observed between social support for PA from family and friends, the home environment for exercise, and aesthetic qualities of the neighborhood environment and LTPA. Within the social environment, main effects were in line with well-established findings in the literature, which consistently demonstrate the importance of social support for LTPA in adults (33-35), rural adults (36), cancer survivors (37,38), and rural cancer survivors (8,39). Within the built environment domain, main effects were also consistent with past research concerning built environmental factors that support LTPA (40). Prior investigations examining links between the built environment and LTPA among rural populations have similarly reported effects of perceived neighborhood environmental supports in the form of aesthetics, walkability, and access to facilities (15,41).
Results from moderation analyses showed a stronger positive association between social and built environmental factors and LTPA in rural cancer survivors who were in the action or maintenance stages of change compared with those in the precontemplation, contemplation, or preparation stages. Among cancer survivors who were not regularly active, there was a weak positive association between subjective social status in the United States and LTPA. The association between subjective social status in the United States and LTPA was stronger in those who were currently active. Rural cancer survivors who reported high social status and who were regularly active reported nearly 1500 more metabolic equivalent of task minutes of LTPA per week compared with those with the same social status who were not regularly active. Aspects of social status, such as income, are positively associated with leisure time, and past research has shown, for example, that socioeconomic inequalities account for differences in LTPA (42). This may explain why LTPA was low for rural survivors with low perceived social status even when they reported being regularly active or greater motivational readiness for exercise. Among rural survivors with the highest perceived social status, and presumably, more leisure time, high prioritization for PA (ie, greater motivational readiness for PA) was positively associated with more LTPA. This finding highlights the need to examine determinants of LTPA beyond person-level factors and to measure multiple levels of influence on LTPA as part of PA intervention development when studying specific populations, such as rural cancer survivors (11,43).
Results from this study hold several implications for intervention development. Important takeaways are that there are multiple levels of influence on LTPA among rural cancer survivors, environmental contexts are important determinants of LTPA, and influences on LTPA interact across levels. Findings directly correspond to the core principles of SEMs of health behavior (13) and suggest interventions that aim to increase motivational readiness for LTPA at the individual level may benefit rural cancer survivors with higher subjective social status but may be insufficient for cancer survivors with lower social status or social capital (44). Other social environment factors that should be targeted based on our results include social connectedness and social support for exercise from family and friends, which have been shown to speed the diffusion of health behaviors in rural adults and within social networks (45-47). Similar to previous studies in rural adults, we found that neighborhood features that supported LTPA were living in a safe and aesthetically pleasing neighborhood with limited traffic and access to recreational facilities (47). Although opportunities to change or manipulate aspects of the neighborhood environment may be limited without broader municipal support (48), results suggest that providing rural cancer survivors with PA equipment could be an effective intervention to promote LTPA at the level of the home environment.
This study addressed a notable gap in the literature by examining the associations between social and built environmental factors and LTPA in rural cancer survivors and used the SEM to guide analyses. Despite extensive research on social and built environmental factors and LTPA in the general population (49-52), few studies have explored these associations among cancer survivors (53,54), and none have explored these in rural cancer survivors.
Despite strengths, some limitations must be considered. First, data were cross-sectional and collected via self-report. Moderation analyses were exploratory in nature. Therefore, results should be interpreted with caution. Future work is needed to assess associations between social and built environmental factors and measured PA. Another limitation was the lack of racial and ethnic diversity within our study. Cancer survivors included in this study were representative of those residing in central Pennsylvania. Although we used rigorous methodology to sample cancer survivors relative to population size from a state-based registry (8), there may be a relatively small sample of cancer survivors in a single region in the United States. Thus, the diversity of environmental features and populations that characterize rural areas and populations nationwide may not be represented in this sample, limiting the generalizability of findings to cancer survivors outside of central Pennsylvania. Future studies should aim to include additional racially and ethnically diverse rural communities to increase generalizability of findings and use a SEM-aligned approach to explore multilevel determinants of LTPA in these communities. Moreover, it is prudent to further understand why certain groups may be underrepresented in investigations such as this and to address these barriers in future studies (55-57).
Results from this cross-sectional study provide empirical evidence to support the use of a socio-ecological perspective to understand multilevel determinants of LTPA in rural cancer survivors. Given the importance of regular PA for cancer survivorship, additional work is needed to elucidate and target socio-ecologic determinants of LTPA more broadly among rural cancer survivors. Results from this study can inform the development of multilevel interventions to promote LTPA and reduce cancer health disparities in cancer survivors residing in rural and medically underserved areas.
Supplementary Material
Contributor Information
Courtney J Stevens, Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; Cancer Population Sciences, Dartmouth Cancer Center, Lebanon, NH, USA.
Yue Liao, Department of Kinesiology, University of Texas at Arlington, Arlington, TX, USA.
Minxing Chen, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Natalia I Heredia, Department of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA.
Hannah Arem, Healthcare Delivery Research Program, Medstar Health Research Institute, Washington, DC, USA; Department of Oncology, Georgetown University, Washington, DC, USA.
Jasmine Sukumar, Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Lenat Joffe, Department of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Cohen Children’s Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA.
Kathryn H Schmitz, Hillman Cancer Center and Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
Scherezade K Mama, Department of Health Disparities Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Data availability
The data underlying this article cannot be shared to protect the privacy of individuals that participated in the study. However, a limited de-identified dataset will be made available by the corresponding author upon request.
Author contributions
Conceptualization: CJS, YL, SKM. Methodology: CJS, MC, SKM. Formal analysis: MC. Data curation: MC, SKM. Writing—Original Draft: CJS, MC, SKM. Writing—Review & Editing: CJS, YL, MC, NIH, HA, JS, LJ, KHS, SKM. Project administration: KHS, SKM. Funding acquisition: SKM.
Funding
The Partnering to Prevent and Control Cancer study was supported by a grant with the Pennsylvania Department of Health using Tobacco CURE Funds (TRK08-Mama-PSU-2016F to SM). CS (K08 CA259632) and SM (grant number K07 CA222335) are supported by career development awards, and this work was supposed, in part, by the National Cancer Institute at the National Institutes of Health (R25 CA203650). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.
Conflicts of interest
CJS, YL, MC, NIH, HA, JS, LJ, KHS, and SKM declare no conflicts of interest.
Acknowledgements
The authors thank the cancer survivors who participated in the Partnering to Prevent and Control Cancer (PPCC) study and the numerous community partners who assisted with recruitment.
Role of the funder: The funder did not play a role in the design of the study; the collection, analysis, and interpretation of the data; the writing of the manuscript; and the decision to submit the manuscript for publication.
Disclaimers: The Pennsylvania Department of Health specifically disclaims responsibility for any analyses, interpretations or conclusions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this article cannot be shared to protect the privacy of individuals that participated in the study. However, a limited de-identified dataset will be made available by the corresponding author upon request.