Showing papers in "Journal of Rural Health in 2013"

Understanding and Addressing Barriers to Implementation of Environmental and Policy Interventions to Support Physical Activity and Healthy Eating in Rural Communities

Abstract: Purpose Rural residents are at greater risk of obesity than urban and suburban residents. Failure to meet physical activity and healthy eating recommendations play a role. Emerging evidence shows the effectiveness of environmental and policy interventions to promote physical activity and healthy eating. Yet most of the evidence comes from urban and suburban communities. The objectives of this study were to (1) identify types of environmental and policy interventions being implemented in rural communities to promote physical activity or healthy eating, (2) identify barriers to the implementation of environmental or policy interventions, and (3) identify strategies rural communities have employed to overcome these barriers. Methods Key informant interviews with public health professionals working in rural areas in the United States were conducted in 2010. A purposive sample included 15 practitioners engaged in planning, implementing, or evaluating environmental or policy interventions to promote physical activity or healthy eating. Findings Our findings reveal that barriers in rural communities include cultural differences, population size, limited human capital, and difficulty demonstrating the connection between social and economic policy and health outcomes. Key informants identified a number of strategies to overcome these barriers such as developing broad-based partnerships and building on the existing infrastructure. Conclusion Recent evidence suggests that environmental and policy interventions have potential to promote physical activity and healthy eating at the population level. To realize positive outcomes, it is important to provide opportunities to implement these types of interventions and document their effectiveness in rural communities.

The metabolic syndrome: are rural residents at increased risk?

Abstract: Purpose The purpose of this study was to estimate the differences in prevalence of metabolic syndrome and its individual components across rural-urban populations, as well as to determine the risk factors associated with metabolic syndrome and examine how they contribute toward rural-urban disparity. Methods Data came from the 1999-2006 National Health and Nutrition Examination Survey, restricting to 6,896 participants aged 20 years or more with complete information. Metabolic syndrome was defined using the National Cholesterol Education Program's Adult Treatment Panel III criteria. Residence was measured at the census tract level using the Rural-Urban Commuting Area Codes. We estimated the prevalence of metabolic syndrome and its components by residence. Multiple logistic regression models were used to examine urban-rural differences after adjusting for sociodemographic, health, dietary, and lifestyle factors. Results The prevalence of metabolic syndrome was higher in rural than urban residents (39.9% vs 32.8%), among both men (39.7% vs 33.3%) and women (40.2% vs 32.3%, respectively). The age and sex adjusted OR for metabolic syndrome in rural as compared to urban residents was 1.23 (95% CI, 1.02-1.49), which was attenuated to 1.06 (95% CI, 0.90-1.25) after adjusting for covariates. Older age, lower physical activity, higher screen time, higher meat intake, and skipping breakfast were associated with increased odds of metabolic syndrome. Conclusion Rural dwelling was associated with higher prevalence of metabolic syndrome among adults in the Unites States, which can be attributed to the differences in demographic composition and obesity-related behavioral factors between urban and rural residents.

Perceived Barriers, Resources, and Training Needs of Rural Primary Care Providers Relevant to the Management of Childhood Obesity

Abstract: Purpose To explore the perceived barriers, resources, and training needs of rural primary care providers in relation to implementing the American Medical Association Expert Committee recommendations for assessment, treatment, and prevention of childhood obesity. Methods In-depth interviews were conducted with 13 rural primary care providers in Oregon. Transcribed interviews were thematically coded. Results Barriers to addressing childhood obesity fell into 5 categories: barriers related to the practice (time constraints, lack of reimbursement, few opportunities to detect obesity), the clinician (limited knowledge), the family/patient (family lifestyle and lack of parent motivation to change, low family income and lack of health insurance, sensitivity of the issue), the community (lack of pediatric subspecialists and multidisciplinary/tertiary care services, few community resources), and the broader sociocultural environment (sociocultural influences, high prevalence of childhood obesity). There were very few clinic and community resources to assist clinicians in addressing weight issues. Clinicians had received little previous training relevant to childhood obesity, and they expressed an interest in several topics. Conclusions Rural primary care providers face extensive barriers in relation to implementing recommended practices for assessment, treatment, and prevention of childhood obesity. Particularly problematic is the lack of local and regional resources. Employing nurses to provide case management and behavior counseling, group visits, and telehealth and other technological communications are strategies that could improve the management of childhood obesity in rural primary care settings.

The financial performance of rural hospitals and implications for elimination of the Critical Access Hospital program

Abstract: Purpose: To compare the financial performance of rural hospitals with Medicare payment provisions to those paid under prospective payment and to estimate the financial consequences of elimination of the Critical Access Hospital (CAH) program. Methods: Financial data for 2004-2010 were collected from the Healthcare Cost Reporting Information System (HCRIS) for rural hospitals. HCRIS data were used to calculate measures of the profitability, liquidity, capital structure, and financial strength of rural hospitals. Linear mixed models accounted for the method of Medicare reimbursement, time trends, hospital, and market characteristics. Simulations were used to estimate profitability of CAHs if they reverted to prospective payment. Findings: CAHs generally had lower unadjusted financial performance than other types of rural hospitals, but after adjustment for hospital characteristics, CAHs had generally higher financial performance. Conclusions: Special payment provisions by Medicare to rural hospitals are important determinants of financial performance. In particular, the financial condition of CAHs would be worse if they were paid under prospective payment.

Alcohol consumption, obesity, and psychological distress in farming communities-an Australian study.

Abstract: Purpose: Alcohol consumption patterns nationally and internationally have been identified as elevated in rural and remote populations. In the general Australian population, 20.5% of adult males and 16.9% of adult females drink at short-term, high-risk levels. Farmers are more likely to drink excessively than those living in major cities. This study seeks to explore the relationships between farmers’ physical and mental health and their alcohol consumption patterns. Our hypothesis is that farmers consume alcohol at high-risk levels more often than the Australian average and that this consumption is associated with obesity and psychological distress. Methods: Cross-sectional descriptive data were collected within Australian farming communities from 1,792 consenting adults in 97 locations across Australia. Data on anthropometric measurements, general physical attributes and biochemical assessments were used to explore the interrelationships of self-reported alcohol consumption patterns with obesity, psychological distress, and other physical health parameters. Findings: There was a higher prevalence of short-term, high-risk alcohol consumption (56.9% in men and 27.5% in women) reported in the study compared with national data. There was also a significant positive association between the prevalence of high-risk alcohol consumption and the prevalence of obesity and abdominal adiposity in psychologically distressed participants. Conclusions: The prevalence of short-term, high-risk alcohol consumption practices in this cohort of farming men and women is significantly higher than the Australian average. These consumption practices are coupled with a range of other measurable health issues within the farming population, such as obesity, hypertension, psychological distress, and age.

Regional Differences in Prescribing Quality Among Elder Veterans and the Impact of Rural Residence

Abstract: Older adults comprise 13% of the United States population yet consume approximately one-third of prescriptions.1 A national (United States) survey of non-institutionalized people over 65 years found that 71% of men and 81% of women use at least one medication per week, and 19% of men and 23% of women use 5 or more.2 Expanding drug regimens yield important therapeutic benefits, but they also place older adults at risk for adverse drug events, as number of medications is a powerful risk factor.3-5 In addition, advancing age is associated with increased physiological susceptibility to adverse drug events, due to both increased pharmacodynamic sensitivity and impaired drug clearance from renal and hepatic dysfunction.6 The combined impact of these factors makes medication safety a critical public health concern for older adults. In addition to quantity, the quality of medication prescribing is important for older adults. Prescribing quality refers to the safe and effective use of medications and, as with other domains of health care quality, is often measured using quality indicators. Prescribing quality indicators commonly include explicitly defined lists of prescribing scenarios that represent potentially inappropriate prescribing practices and are typically ascertained from electronic administrative data. The term potentially is used because practices considered inappropriate in most cases may be justifiable under certain clinical circumstances. A frequently used example is the Beers criteria, a list of medications where risk generally outweighs benefit for patients over 65 years of age, as established by a consensus panel of experts.7-9 Prescribing quality indicators, such as the Beers criteria, have been linked to risk for adverse drug events.10-17 Ensuring high-quality prescribing among older adults is particularly relevant to the Veterans Affairs (VA) Health Care System, where 45% of enrolled veterans are over 65 years of age.18 Prescribing quality data in VA are limited, but available data suggest that older adult veterans are at similar or slightly lower risk for inappropriate prescribing compared to non-VA patient groups.19,20 One vital piece of missing information is whether significant regional variations in inappropriate prescribing practices exist across VA facilities. Regional variation often reflects discrepancies in the implementation of best practices, and comparisons of high versus low performing sites may identify mechanisms for improving performance.21 A recent analysis of national Medicare data revealed significant regional variation, with the highest concentration of potentially inappropriate prescribing found in the Southern US and the lowest rates in the Northeast and upper Midwest.22 Similar geographic distributions of prescribing quality have been previously reported among older adults in both outpatient and inpatient settings.23,24 The most direct interpretation of these findings are differences in provider-level characteristics, where different approaches to pharmacotherapy lead to patients in low performing regions being exposed to riskier medication regimens. However, prescribing is also influenced by system-level factors such as differences in health system organization, access to prescription drug benefits, and higher copayments for newer (and potentially safer) medications. As regional variation in many of these system-level factors is eliminated, including use of a national formulary, VA presents a unique opportunity to study prescribing quality. If the extent of regional variation is significantly lower in VA, or follows a different pattern, it is likely that system-level factors play an important role in driving regional differences in prescribing quality. However, if regional variation patterns extend to VA, then provider-level factors may play a more substantial role in driving prescribing quality. In addition to regional differences, a focal point for VA has been ensuring equal health care access and quality for rural veterans. Approximately 3.3 million veterans, 41% of total VA enrollees, live in rural areas.25 Rural residence has been associated with problems accessing health care, worse health status, and higher prevalence of chronic diseases.26-30 While there do not appear to be important disparities in access to prescription medications,31 some studies suggest that rural residents may be at increased risk for inappropriate prescribing.23,32 Perhaps most importantly, rural residence has been linked recently to increased risk for fatal adverse drug reactions, which may be mediated by differences in prescribing quality.33 However, the potential impact of rurality on prescribing quality has not been sufficiently studied. The objective of this study was to fill these important knowledge gaps by characterizing geographic variation in potentially inappropriate prescribing practices among older adults in VA, as measured by 4 separate indicators of prescribing quality. To accomplish this objective, we examined prescribing quality variation across 4 major US geographic regions, and we compared rural versus urban residence.

Perspectives on Healthy Eating Among Appalachian Residents

Abstract: Most Americans consume far below the recommended daily intake (RDI) for fruits and vegetables and far above the RDI for suboptimal foods.1–3 Such dietary patterns have been linked to overweight and obesity, metabolic syndrome, and other chronic conditions.4 Rural residents are more likely than their urban counterparts to experience these conditions, oftentimes leading to premature mortality.5 Social determinants, including lower socioeconomic status, lower likelihood of health insurance coverage, and more limited access to safety net and preventive medical services, place rural residents at elevated risk of and from these chronic conditions.6 Kentucky residents, particularly those living in the rural, Appalachian portion of the state, suffer even higher rates of overweight, obesity, and associated chronic conditions than other rural residents.7 In 2005, 62.5% of adults in Kentucky were overweight or obese, as compared to 58.5% for the United States.8 Residents of the eastern Appalachian portion of Kentucky have among the highest rates of obesity and overweight in the United States, estimated between 62.5% and 76.2% (See Figure 1, which also highlights study counties. Data obtained from the CDC’s Behavioral Risk Factor Surveillance System).8–10 Rates of diabetes and cardiovascular disease in Appalachian counties in Kentucky also are among the highest in the state and the United States.10–12 Figure 1 Overweight and Obesity Among Adults in Kentucky 2008–2010 Likely associated with these negative health outcomes, Kentucky ranks third nationally for those least likely to consume the RDI of fruits and vegetables; only 21.1% of Kentuckians and 19% of Appalachian residents meet this RDI, compared with 23.4% of Americans nationwide.13 In part, these consumption patterns stem from regional food ways, which tend to emphasize meats, biscuits, and fried foods over vegetables; these food preferences have become important components of rural Appalachian identities.15 Common uses of locally acquired ingredients and methods of preparation shared among rural Appalachians serve as an expression of belonging that not only reaffirms cultural ties to place, but also to family and community.14 The preference for these unhealthy foods among rural Appalachians, including the expectation that these culturally appropriate foods should be present at home and community events, has been identified as a potential barrier for individuals in the region to making healthy dietary choices.15 Dietary patterns in rural Appalachia also are shaped by a broad range of interacting social, cultural, geographical, and economic processes. For instance, some research has suggested that the economic transition in the region from farming and mining to employment in the service industry has contributed to a rising dependence on fast foods.16 Coupled with issues of food affordability,15 limited access to high-quality grocery stores,17 and increased demands on the use of time, the spiking number of fast food establishments in rural Appalachian communities has been met with a corresponding dependence on these foods in regional diets. This dependence sometimes supplants former food practices which are viewed as more time intensive to prepare.12 Given that Appalachian residents experience disproportionate risk of overweight, obesity, and associated negative health outcomes, new approaches to improve dietary intake are needed. These approaches will be most successful if they are grounded in local perspectives and address the interactions between regional food ways and shifting social, cultural, and economic contexts. Thus, the purpose of this article is to explore how rural, Appalachian residents think about healthy eating and their ideas for improving dietary intake.

Geographic disparities in patient travel for dialysis in the United States

Abstract: Purpose To estimate travel distance and time for US hemodialysis patients and to compare travel of rural versus urban patients. Methods Dialysis patient residences were estimated from ZIP code-level patient counts as of February 2011 allocated within the ZIP code proportional to census tract-level population, obtained from the 2010 US Census. Dialysis facility addresses were obtained from Medicare public-use files. Patients were assigned to an “original” and “replacement” facility, assuming patients used the facility closest to home and would select the next closest facility as a replacement, if a replacement facility was required. Driving distances and times were calculated between patient residences and facility locations using GIS software. Findings The mean one-way driving distance to the original facility was 7.9 miles; for rural patients average distances were 2.5 times farther than for urban patients (15.9 vs 6.2 miles). Mean driving distance to a replacement facility was 10.6 miles, with rural patients traveling on average 4 times farther than urban patients to a replacement facility (28.8 vs 6.8 miles). Conclusion Rural patients travel much longer distances for dialysis than urban patients. Accessing alternative facilities, if required, would greatly increase rural patient travel, while having little impact on urban patients. Increased travel could have clinical implications as longer travel is associated with increased mortality and decreased quality of life.

“Living With a Ball and Chain”: The Experience of Stroke for Individuals and Their Caregivers in Rural Appalachian Kentucky

Abstract: The “stroke belt,” a group of 11 southeastern states including Kentucky, has the highest incidence and mortality rates of stroke in the United States. Appalachian Kentucky could be considered part of the “buckle” of the belt as the Centers for Disease Control and Prevention reports 26 counties in this region have the highest incidence of stroke in the belt.1 This is in part attributed to lower socioeconomic status, lower per capita incomes, higher poverty rates, lower educational attainment, reduced medical care access, and higher prevalence of chronic health problems that plague Appalachian Kentucky.2–4 Stroke is a leading cause of long-term disability.5 Barriers to stroke management and positive quality of life for individuals with stroke in rural communities include lack of access to health care,6 inability to return to work,7 difficulty balancing expectations and physical capacity,8 and depression.9 Caregivers may experience “lives turned upside-down”10 with stress, depression, and reduced quality of life. Improvements in post-acute care are necessary to reduce disability and stroke-related financial burden.11 In Appalachia, the mortality rates for stroke are higher compared to the rest of the country, and many of the most distressed counties in terms of negative health disparities are in the 54 Appalachian counties of Kentucky.4 Qualitative studies have examined the experiences of African Americans with stroke in rural North Carolina,12 caregivers of stroke survivors in rural Wyoming,13 and stroke survivors and their caregivers in rural Australia.14 Given cultural and demographic differences, however, there may be limitations in the transferability of findings of these studies to rural Appalachian Kentucky. A description of the experience of stroke for survivors and caregivers in this region is important because those who live in Appalachia suffer poorer health and increased risks of negative health outcomes disproportionate to the rest of the United States.15,16 Furthermore, there is a call for “difference-based rural health policy,” in which there is a recognition that rural communities are different and therefore require the development of tailored interventions and supports sensitive to the economic, cultural, and social factors specific to the region.17 Gaining an understanding of the experiences of stroke for survivors and caregivers is the first step toward development of tailored interventions and supports. The purpose of this study is to describe the experience of stroke for survivors and their caregivers in rural Appalachian Kentucky. We approached the study with 3 main points of emphasis regarding survivors’ and caregivers’ experience of stroke: 1) experience of the onset of the stroke, 2) experience of the health care continuum, and 3) experience with attempted rural community reintegration post-stroke. To our knowledge, this is the first qualitative study investigating the experiences of stroke survivors and their caregivers in Appalachian Kentucky.

Access to care and impacts of cancer on daily life: do they differ for metropolitan versus regional hematological cancer survivors?

Abstract: Purpose Little is known about access to care for hematological cancer patients This study explored patient experiences of barriers to accessing care and associated financial and social impacts of the disease Metropolitan versus nonmetropolitan experiences were compared Methods A state-based Australian cancer registry identified adult survivors of hematological cancers (including lymphoma, leukemia and myeloma) diagnosed in the previous 3 years Survivors were mailed a self-report pen and paper survey Findings Of the 732 eligible survivors, 268 (37%) completed a survey Forty percent of participants reported at least one locational barrier which limited access to care Only 2% reported cancer-related expenses had restricted their treatment choices Almost two-thirds (64%) reported at least one financial or social impact on their daily lives related to cancer The most frequently reported impacts were the need to take time off work (44%) and difficulty paying bills (21%) Survivors living in a nonmetropolitan location had 17 times the odds of reporting locational or financial barriers compared with those in metropolitan areas Preferred potential solutions to alleviate the financial and social impacts of the disease were: free parking for tests or treatment (37%), free medications or treatments (29%), and being able to get treatment in their local region (20%) Conclusions Providing more equitable access to care for hematological cancer patients in Australia requires addressing distances traveled to attend treatment and their associated financial and social impacts on nonmetropolitan patients Greater flexibility in service delivery is also needed for patients still in the workforce

Health Literacy and Urbanicity Among Cancer Patients

Abstract: Low health literacy is an extensive problem in the United States. Approximately 80 million adults (36%) have limited health literacy.1, 2 Low health literacy is increasingly recognized as an important individual-level predictor of poor overall health and higher mortality among seniors.1, 3, 4 Research indicates those with low health literacy may have difficulty understanding, obtaining, and retaining health information.5 Low health literacy is also associated with under-utilization of preventive health care services, increased use of emergency services and hospitalizations, and worse physical functioning and mental health.1, 5–8 Broadly defined, the term “health literacy” encompasses an array of skills required to understand health and to function in a health care environment. The Institute of Medicine defined health literacy as the “degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.”9 The American Medical Association states that health literacy is a “constellation of skills that constitute the ability to perform basic reading and numerical tasks for functioning in the health care environment and acting on health care information.”10 Health literacy has been found to be an important factor for cancer prevention and control.3, 11 Adults with limited literacy obtain less information from cancer prevention and control materials and may be less likely to be screened for cancer.11 For instance, a review of the literature found that low health literacy is associated with a lower probability of mammography screening.1, 4 Low literacy is also associated with a 1.6 times higher odds of being diagnosed at a later stage of prostate cancer and having an inadequate understanding of complex information about cancer.11, 12 Low health literacy may hinder cancer patients’ ability to understand consent forms, follow medication directions, and manage their disease.3, 5, 11 Previous research has examined the association between health literacy and sociodemographic factors, including income, education, racial and ethnic minority status, age, and recent immigration to the United States.1, 3, 5, 11, 13 Health literacy has also been associated with lack of insurance coverage.2 Results from the National Assessment of Adult Literacy (NAAL) showed that, among US adults without health insurance, 28% had low (below basic) health literacy.2 Relatively less attention has been paid to the relationship between health literacy and place of residence (urbanicity). Previous research has indicated that living in rural and non-metropolitan areas is associated with higher incidence of late-stage lymphoma and prostate cancer and lower survival rates among lymphoma patients.14, 15 Studies have shown that rural residence is also associated with lower cancer screening rates, later diagnosis stage, as well as a higher incidence of lung, prostate, colon, and cervical cancer in specific US regions.14, 16–18 Whether health literacy may explain, at least partially, these associations is unknown. Rural areas are disproportionately represented among US counties designated as medically underserved and have fewer physicians, specialists, and hospitals per capita than their urban counterparts.19, 20 One study reported no difference in health literacy between rural and urban residents.13 Instead, the results of that study suggested a U-shaped curve with lower literacy levels in urban and rural areas and higher health literacy in suburban areas.13 Characteristics typically associated with low health literacy (eg, poverty, inadequate or lack of health insurance, and the absence of a usual source of care) are more concentrated among residents of rural areas and could result in worse health outcomes and health care access for rural cancer patients independent of health literacy levels.18–20 Health literacy research has called for further investigation into sociodemographic characteristics as potential mediators, rather than confounders of relationships between health literacy and other variables such as health care utilization and health outcomes.6, 7 Cancer patients residing in medically underserved or rural areas may have lower income and education levels than patients in more urbanized areas. These socioeconomic factors could be associated with lower health literacy levels among rural patients compared to those living in more urbanized regions. Therefore, socioeconomic status could explain, at least to some extent, the relationship between rural residency and lower health literacy levels. This study attempts to fill the gaps in knowledge regarding the relationship between urbanicity and health literacy by a) investigating the association between rural residence and health literacy in a population-based sample of cancer patients in Wisconsin, and b) testing whether education, income, and other sociodemographic factors mediate this relationship.

Personal and Family Health in Rural Areas of Kentucky With and Without Mountaintop Coal Mining

Abstract: Purpose This study investigates health disparities for adults residing in a mountaintop coal mining area of Appalachian Kentucky. Mountaintop mining areas are characterized by severe economic disadvantage and by mining-related environmental hazards. Methods A community-based participatory research study was implemented to collect information from residents on health conditions and symptoms for themselves and other household members in a rural mountaintop mining area compared to a rural nonmining area of eastern Kentucky. A door-to-door health interview collected data from 952 adults. Data were analyzed using prevalence rate ratio models. Findings Adjusting for covariates, significantly poorer health conditions were observed in the mountaintop mining community on: self-rated health status, illness symptoms across multiple organ systems, lifetime and current asthma, chronic obstructive pulmonary disease, and hypertension. Respondents in mountaintop mining communities were also significantly more likely to report that household members had experienced serious illness, or had died from cancer in the past 5 years. Significant differences were not observed for self-reported cancer, angina, or stroke, although differences in cardiovascular symptoms and household cancer were reported. Conclusions Efforts to reduce longstanding health problems in Appalachia must focus on mountaintop mining portions of the region, and should seek to eliminate socioeconomic and environmental disparities.

"Fault-line of an earthquake": a qualitative examination of barriers and facilitators to colorectal cancer screening in rural, Eastern North Carolina.

Abstract: Purpose: Colorectal cancer (CRC) is a leading cause of cancer mortality and disparately affects rural, low-income and minority individuals. Thus, to inform effective interventions and policies to increase screening rates and thus ameliorate CRC disparities, this study's purpose was to examine barriers and facilitators to CRC screening among low-income, rural eastern North Carolina residents. Methods: We conducted 4 focus group discussions in October and November 2011, among a convenience sample of eastern North Carolina residents (n = 45). The focus group discussion guide included open-ended questions about barriers and facilitators to CRC screening. Discussions were audio recorded and then transcribed verbatim. A codebook listing codes and operational definitions was developed by 2 research team members, who then iteratively and independently double-coded all transcripts. Nvivo (version 9, QSR International Pty Ltd, Doncaster, Victoria, Australia) was used to manage data. Themes were extracted based upon depth and frequency of mention. Findings: Major barriers to CRC screening included the high cost of tests and follow-up care, fear of the test itself (colonoscopy), fear of cancer diagnosis, and fear of burdening family members. Violation (among men) and embarrassment (among women) were also barriers. Facilitators included doctor's recommendation, symptoms, support from family and friends, and the desire to live a long and healthy life. Intervention ideas included free tests with information and resources for follow-up care as needed. Conclusion: Understanding barriers and facilitators to CRC screening can assist clinicians and public health practitioners in designing effective interventions to reduce CRC disparities.

Promoting heart health in rural women.

Abstract: Cardiovascular disease (CVD) is the number 1 cause of death in the world. Over one-third of Untied States (US) women aged 20 and older had some form of CVD in 20081;of these, 47.3% were black and 33.8% white. Prevalence rates of CVD specific for rural dwellers are outdated and difficult to extrapolate from national data.2 Rural Healthy People 2010 indicated rural populations have higher CVD morbidity, particularly in the South and Appalachian portions of the US.3 Although some note a higher prevalence of CVD risk factors in rural populations,4 very few studies have specifically identified the cardiovascular risk burden for rural US populations and these are usually small, descriptive, regional studies.5–8 One study conducted in New Mexico found that “rural patients, regardless of ethnicity received significantly fewer targeted CVD treatments and were less likely to reach blood pressure goals compared with urban patients.9(p420) Most agree there are limitations in access to health care, particularly specialty care, in rural areas. Cardiology services are often regionalized and may be less accessible to rural populations, who must deal with distance and transportation issues. One study found echocardiogram utilization among rural veterans was limited by distance.10 Another study found that transfer of Acute Myocardial Infarction (MI) patients from rural to more tertiary care facilities reduced inhospital mortality; however, women were transferred less frequently,11 possibly indicating another gap in cardiovascular care for rural women. Smoking, hypertension, hyperlipidemia and diabetes are known major risk factors associated with increased lifetime risk for CVD and decreased median survival rates.1 Elevated levels of C-reactive protein (CRP) may increase the risk of CVD in women.12 Other recognized modifiable risk factors for CVD include physical inactivity, obesity, and abdominal adiposity.13 Although rural often evokes visions of outdoor work with a physically fit population, this is not always the case. As rural America has become less agriculturally based and more mechanized, rural women have fewer opportunities for physical activity, which in turn increases their cardiovascular risk. Although current literature does not answer the question of whether US rural women have a higher CVD burden than their urban counterparts, it is clear that CVD, as the number 1 killer of women,1 is negatively affecting the health of all women including those living in rural areas, and thus intervention is warranted. Modifying diet, physical activity and smoking can reduce CVD risks and improve morbidity and mortality rates.14 Even modest behavioral changes have benefits, especially if sustained. However, making and sustaining lifestyle modifications is not easily accomplished. A major gap in the literature exists regarding study interventions lasting more than 6 months. Moreover, results are mixed on whether to approach lifestyle modification from sequential or combined interventions.14 The purpose of this study was to compare 2 strategies, Stage Matched Nursing and Community Intervention (SMN+CI), and Community Intervention (CI) alone, in reducing cardiovascular risk factors and improving risk markers among rural women. This study sought to reduce modifiable cardiovascular risk factors in up to 3 behavioral areas: diet, physical activity, and/or smoking. Theoretical underpinnings for this study included the Transtheoretical model (TM)15 as well as a social-ecological model to account for both environmental and personal systems in health-related behavior and status.16 Transtheoretical model included assessment of stage of change (SOC) at 5 levels (eg, pre-contemplation, contemplation, preparation, action and maintenance).15 The Moos model16 was chosen to help address environmental system limitations (eg, few sidewalks or safe places to exercise in rural communities) and the fact that many rural women drive long distances to work, thus limiting time for physical activity. Specific aims included determining whether rural women, ages 35 to 65 in the group that received SMN+CI, would have greater changes than those in the CI group on: 1) dietary intake, physical activity, and/or smoking; 2) forward movement through the SOC for behavioral action relative to dietary intake of fruits and vegetables, fats, fiber; intention for weight loss, and physical activity; and 3) improvement on selected modifiable cardiovascular risks as measured on the Framingham Coronary Disease Risk Prediction tool (Framingham), serum levels for CRP, lipids, and cotinine for those reporting smoking within the last 2 years, and anthropometric outcomes including blood pressure (BP), body mass index (BMI), and waist circumference.

The Influence of Rural Versus Urban Residence on Utilization and Receipt of Care for Chronic Low Back Pain

Abstract: Purpose: (1) To describe demographic and health-related characteristics among rural/urban residents with chronic low back pain (LBP); (2) To determine if the utilization of diagnostics and treatments differs between rural and urban residents with chronic LBP; and (3) To determine the association between rural/urban residence and health care provider usage and if associations differ by race or gender. Methods: A 2006 cross-sectional telephone survey of a representative sample of North Carolina residents. Subjects with chronic LBP were questioned regarding their health and health care use. Wald and chi-square tests were used to determine differences between demographic and health-related characteristics of rural/urban residents. Logistic regression was used to determine the association between rural/urban residence and health care provider use. Differences in race or gender were explored with stratified analysis with a P < .10. Findings: 588 residents of North Carolina with self-reported chronic LBP sought care from a provider in the previous year. In bivariate analyses, when compared to urban residents, rural residents were younger, more likely to be uninsured, reported significantly higher levels of disability, and reported more depression/sadness. Rural residents were less likely to receive care from a rheumatologist (adjusted odds ratio [aOR] 0.47 [95% CI, 0.22-0.99]). Rural blacks were less likely to receive care from a physical therapist when compared to urban blacks (aOR 0.26 [95% CI, 0.07-0.87]). Conclusion: Despite similarities of high provider use, imaging and therapeutics, when compared to urban residents, rural residents reported higher levels of functional limitation and depression.

Prevalence of and factors associated with subclinical posttraumatic stress symptoms and PTSD in urban and rural areas of Montana: a cross-sectional study.

Abstract: Purpose Posttraumatic stress disorder (PTSD) is an important clinical problem, but little is known about PTSD in rural, nonclinical populations. To better understand PTSD in rural areas, we examined the prevalence and risk and protective factors in urban, rural, and highly rural communities in Montana for both subclinical posttraumatic stress symptoms (PTSS) and PTSD. Methods We compared the prevalence of PTSS and PTSD in urban, rural, and highly rural communities in bivariate and multivariable regression analyses using self-reported cross-sectional survey data from the Montana Health Matters study (N = 3,512), a state-representative household-based survey done in 2010-2011. We also explore potential risk and protective factors for PTSS and PTSD and whether risk and protective factors for each differ by rurality. Findings There were no differences in the level of PTSS by rurality in bivariate or multivariate models, and the bivariate relationship between rurality and PTSD became nonsignificant in a multivariate model. Only locus of control was predictive for PTSS; however, gender, age, marital status, income, employment status, community fit, locus of control, and religiosity were associated with PTSD. Some risk and protective factors operate differently by rurality. Conclusions Although our findings are subject to weaknesses common to cross-sectional data and are based on questionnaire reports, it appears that there are different risk and protective factors for PTSS and PTSD, suggesting that PTSD may be qualitatively different from PTSS. Furthermore, differences in risk and protective factors across urban and rural communities suggest more attention is needed to understand PTSD in rural communities.

China's New Rural Cooperative Medical Scheme and Underutilization of Medical Care Among Adults Over 45: Evidence From CHARLS Pilot Data

Abstract: Purpose With its population rapidly aging, China needs prompt action to facilitate the middle-aged and senior citizens' utilization of health care. The New Rural Cooperative Medical Scheme (NCMS), a health care reform initiative started in 2003, is currently China's primary insurance program for the rural population. Methods With a 2-province pilot sample (Gansu, the poorest province, and Zhejiang, one of the richest) of people over age 45 from the China Health and Retirement Longitudinal Study (CHARLS), this paper used logistic regressions to examine the association between the coverage of New Rural Cooperative Medical Scheme and the underutilization of medical care. Findings Among those who had a need to visit a health care provider during the previous month, people covered by NCMS were more likely to underutilize outpatient care than the uninsured (Odds Ratio = 5.610, 2.035-15.466). As for those who had a need to be hospitalized in the past year, the association between NCMS coverage and the underutilization of inpatient care was not statistically significant (Odds Ratio = 1.907, 0.335-10.862). Low total household expenditure per capita, living in the inland province of Gansu, and being an urban resident were also associated with underutilizing outpatient care. Conclusion Further research is needed to understand the negative association between NCMS coverage and outpatient care utilization.

Rural-urban disparities in quality of life among patients with COPD.

Abstract: Examination of geographic variation in disease occurrence and other disease measures provides a method for detection of gaps in quality of public health activities and clinical health care services.1 Moreover, regional variations in health care costs and outcomes have focused attention on the need and opportunity for improvements in delivery of health care in the US.2 These analyses have largely been conducted using administrative databases of specific populations including Medicare,3 Medicaid, Veterans Administration4,5 (VA), and hospitals.6 Regional and system-level variation for a number of chronic obstructive pulmonary disease (COPD)-related measures has been found in the US and worldwide. The populations studied in the US have largely included health and hospital systems with variations found in use of diagnostic spirometry,7 health status,8 exacerbation/hospitalization rates,3,4,9-12 quality of care,6 and mortality.13 Of these studies 2 have focused on rural-urban differences in mortality in the VA13 and hospitalization rates among Texas hospitals.10,11 While these studies provide evidence for substantial variation in a number of outcomes, limited evidence is available on factors to explain these regional variations. In Texas, Jackson et al. found higher rates of hospitalization for COPD in non-metropolitan counties11 Regional differences in the distribution of racial and ethnic groups, and indices of regional isolation including concentration of non-metropolitan counties, hospitals, and pulmonary specialists were all associated with higher hospitalization rates.10 However, this analysis was limited because of inherent limitations of administrative data, which lacks data on clinical characteristics and other potential determinants of health outcomes. To further examine reasons for these regional differences in COPD hospitalization rates we used detailed patient-specific data from a clinical trial to examine the relationships between rural vs urban residence location and outcomes including patient-reported health status and health care utilization among patients with COPD.

Disparities in Knowledge of Mouth or Throat Cancer Among Rural Floridians

Abstract: In the United States, there will be 52,100 new cases of cancers of the mouth and throat (MTC) diagnosed in the next year, with approximately 11,460 deaths.1 Oral cancer is preceded by visible changes in the oral mucosa, allowing clinicians to detect and treat effectively early intraepithelial stages of oral carcinogenesis.2 Nevertheless, most oral cancers are currently detected at a late stage, when treatment is complex and costly, and poor outcomes are likely. The 5-year relative survival rate among cases localized at diagnosis show disparities between blacks and whites among both males (56% vs 66%) and females (64% vs 71%).3 Lack of awareness among the public of the signs, symptoms, and risk factors for oral cancer, as well as an absence of prevention and early detection by health care providers, are believed to be responsible for the diagnostic delay.4 National data from the 1990 National Health Interview Survey (NHIS) indicated that only 25% of adults could correctly identify one early sign of MTC, and correct identification of risk factors ranged from 13% for alcohol use to 67% for tobacco use.5 Since that time, data from statewide surveys have suggested that levels of knowledge of MTC are increasing.5-9 Generally, there have been 2 strategies used to assess MTC knowledge. The simplest is to directly ask respondents for their subjective rating of MTC awareness—either, “Have you heard of MTC? (often called oral cancer)” or, “How much do you know about MTC?” State-level data from Maryland, North Carolina, New York, and Florida suggest that 15%-20% of residents have never heard of MTC.6-9 The second method to test knowledge has been to ask more specific questions about MTC. Knowledge of risk factors has typically been asked in a format where respondents rate the likelihood of a stated behavior increasing a person’s risk for MTC, often along with several foils. Other studies ask more specific questions about MTC signs and symptoms—often by open-ended questions.6-8 These studies have generally found that respondents know little about MTC. Health literacy refers to the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.10 Low health literacy is common, with a recent review of this literature of studies in the US concluding that 26% of participants were classified as having low health literacy.10 Because low health literacy is so common, it is important to understand how low health literacy can affect one’s health, both directly and indirectly. Our previously published work demonstrates an association between low health literacy in males and lack of MTC exam awareness.11 Also present in the literature are studies exploring the effects of health conditions such as depression on secondary prevention behaviors. For example, data from population-based studies in the US,12,13 Canada,14 and England15,16 have found that higher depressive symptoms predict reduced use of mammography. However, associations between depression and cervical cancer screenings are less consistent.13,14,17 Currently lacking are studies examining the presence or absence of participants’ health literacy levels on screening behaviors, specifically in the presence of chronic conditions such as depression. Also lacking are studies directly assessing health literacy levels, MTC knowledge and/or concern, and depressive symptoms within the individuals’ environmental context; ie, rural versus urban residence. Rural communities face unique and formidable access to care barriers—barriers placing them at a greater risk for experiencing chronic disease and cancer.18-20 Out-migration (leaving rural communities to move to urban areas) of younger residents has resulted in rural communities typically composed of individuals who are older, less educated, more likely to report their health as poor, and have reduced access to primary health care providers.21 Also resulting from geographic isolation and rurality are increased concentrations of minority populations, poor whites, higher rates of unemployment and poverty, and lower rates of education,21 all of which are barriers to accessing health care. Other barriers attributed to geographic isolation include fewer services such as cell phone service, broadband or other high-speed Internet technology.22 Because most health care providers locate in densely populated metro areas, nearly 80% of non-metropolitan US counties are classified as either whole or partial primary health care professional shortage areas (HPSA); 60% of nonmetropolitan counties are in dental care HPSAs. The percentage of rural residents lacking health insurance ranges from 20% to 30%, with lack of dental insurance even more common. Rural residents access health care via small private medical/dental practices or rural health care clinics usually offering limited, episodic and primary care service.18 Assuming improved health literacy results from increased health care provider contact, residents of HPSA are expected to have lower levels of health literacy than those living in urban areas. As a result, lower levels of health literacy, compounded by an overall lack of resources, including medical/dental specialists, cause rural residents to access/receive fewer preventive cancer services than urban residents.23,24 Also adding to the burden of cancer for rural communities is the high prevalence of risk factors such as cigarette smoking, sun exposure, poor diet, physical inactivity, alcohol consumption, and human papillomavirus infection.25,26 Urban residents wishing to access medical/dental care, including examinations for secondary cancer prevention, face far fewer barriers than do their rural counterparts. The formidable barriers faced by rural residents when accessing health care cause them to be at increased risk of late-stage diagnosis for cancer in general.27-30 As a whole, rural residents experience fewer medical and dental visits, spend little to no time using technology, and can have limited access to television and radio. In addition, contact with others is limited by geography and transportation issues. Each of these factors interferes with rural residents’ exposure to knowledge and services, especially in relation to cancer. Limited time with health care practitioners, combined with limited or no access to the Internet and/or other types of technology lowers opportunities for patient education. Although commonly used pamphlets and posters offer cancer information and resources, low levels of literacy, both health and general, limit their educational effectiveness. The aims of this study are to document the level of MTC knowledge and concern among residents of rural North Florida and then to determine risk factors of lack of knowledge and concern. Specific hypotheses include that (1) males, older adults, and blacks living in rural North Florida possess reduced MTC knowledge and concern, and (2) that among this rural sample depression and lower levels of education and health literacy are associated with an individual’s increased risk for low levels of MTC knowledge and concern.

Maternal Obesity and Gestational Weight Gain in Rural Versus Urban Dwelling Women in South Carolina

Abstract: Purpose: An unhealthy prepregnancy weight and/or gaining an inappropriate amount of weight during pregnancy increase the risk for poor pregnancy and birth outcomes. To our knowledge, no studies to date have examined differences in prepregnancy body mass index (BMI) and gestational weight gain (GWG) patterns by rurality. Methods: The 2004-2006 South Carolina birth certificate data (n = 132,795) were used. Rurality of residence was determined using Rural-Urban Commuting Area (RUCA) codes. Mothers were categorized as underweight (<18.5 kg/m2), normal weight (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0) using their prepregnancy BMI and as having inadequate, adequate, or excessive GWG according to the Institute of Medicine's 2009 GWG guidelines. Chi-square tests and adjusted multinomial logistic regression were used in analysis. Findings: Rural women had higher odds of being overweight and obese compared to urban women. This relationship was found to be partially explained by the higher proportion of minorities living in rural areas. The relationship between GWG and residence type varied by BMI category. Specifically, among normal weight women, rural women had increased odds of inadequate GWG. Among overweight women, rural women had decreased odds of excessive GWG. In obese women, rural women had decreased odds of both inadequate and excessive GWG. Conclusions: Rural women were more likely to have an unhealthy prepregnancy weight than urban women. However, rural residence was found to be protective against unhealthy GWG in overweight and obese women. Future research exploring reasons for these findings and confirmation of these results in other populations is necessary.

Measuring the performance of Critical Access Hospitals in Missouri using data envelopment analysis.

Abstract: Purpose: Rural hospitals are critical for access to health care, and for their contributions to local economies. However, many rural hospitals, especially critical access hospitals (CAHs) need to strive for more efficiency for continued viability. Routinely evaluating their performance, and providing feedback to management and policy makers, is therefore important. Method: Three measures of relative efficiency are estimated for CAHs in Missouri using an Input-oriented Data Envelopment Analysis with a variable returns to scale assumption and compared with the efficiency of other rural hospitals in Missouri using Banker's F-test. Using 30-day readmission rate as a measure of quality, CAHs are evaluated against efficiency-quality dimensions. Findings: CAHs in Missouri had a slight decline in average technical efficiency, but they had a slight gain in average cost efficiency in 2009 compared to 2006. More than half of the CAHs were neither economically nor technically efficient in both years. The relative efficiency of other rural hospitals was statistically higher than that of CAHs in Missouri. Conclusions: This study validates the finding of relative inefficiency of CAHs compared to other hospitals paid under the Prospective Payment System at a state level (Missouri). However, with considerable variation in socioeconomic as well as health care access indicators across states, a relative efficiency frontier may not be the only relevant indicator of value for the evaluation of the performance of CAHs. Access to health care and the impact on the local economy provided by these CAHs to the community are also critical indicators for more comprehensive performance evaluation.

What We Know About the Effectiveness of Farm Safety Day Programs and What We Need to Know

Abstract: BACKGROUND: Farm safety day camps are grassroots educational interventions organized and conducted by members of a local community. These events are held in an effort to promote safety knowledge and behavior in children who live on family farms or are exposed to the hazards of the agricultural industry. Since the dramatic increase in farm safety day camps beginning in the 1990s, researchers have been called upon to evaluate their effectiveness. PURPOSE: The current paper reviews more than a decade of research, describing what is currently known about the effectiveness of farm safety days and suggesting potential methods for addressing questions regarding gaps in what we know about their effectiveness. CONCLUSIONS: The results of these evaluations indicate that farm safety days have a positive impact on children's safety behavior and knowledge; however, much remains to be investigated regarding the effectiveness and impact of these interventions.

Depression, social factors, and farmworker health care utilization.

Abstract: Purpose Farmworkers frequently live in rural areas and experience high rates of depressive symptoms. This study examines the association between elevated depressive symptoms and health care utilization among Latino farmworkers. Methods Data were obtained from 2,905 Latino farmworkers interviewed for the National Agricultural Workers Survey. Elevated depressive symptoms were measured using the Center for Epidemiologic Studies Depression short-form. A dichotomous health care utilization variable was constructed from self-reported use of health care services in the United States. A categorical measure of provider type was constructed for those reporting use of health care. Results Over 50% of farmworkers reported at least 1 health care visit in the United States during the past 2 years; most visits occurred in a private practice. The odds of reporting health care utilization in the United States were 45% higher among farmworkers with elevated depressive symptoms. Type of provider was not associated with depressive symptoms. Women were more likely to seek health care; education and family relationships were associated with health care utilization. Conclusions Latino farmworkers who live and work in rural areas seek care from private practices or migrant/Community Health Clinics. Farmworkers with elevated depressive symptoms are more likely to access health care. Rural health care providers need to be prepared to recognize, screen, and treat mental health problems among Latino farmworkers. Outreach focused on protecting farmworker mental health may be useful in reducing health care utilization while improving farmworker quality of life.

Characteristics of the Residential Neighborhood Environment Differentiate Intimate Partner Femicide in Urban Versus Rural Settings

Abstract: Purpose: A growing body of work examines the association between neighborhood environment and intimate partner violence (IPV). As in the larger literature examining the influence of place context on health, rural settings are understudied and urban and rural residential environments are rarely compared. In addition, despite increased attention to the linkages between neighborhood environment and IPV, few studies have examined the influence of neighborhood context on intimate partner femicide (IPF). In this paper, we examine the role for neighborhood-level factors in differentiating urban and rural IPFs in Wisconsin, USA. Methods: We use a combination of Wisconsin Violent Death Reporting System (WVDRS) data and Wisconsin Coalition Against Domestic Violence (WCADV) reports from 2004 to 2008, in concert with neighborhood-level information from the US Census Bureau and US Department of Agriculture, to compare urban and rural IPFs. Findings: Rates of IPF vary based on degree of rurality, and bivariate analyses show differences between urban and rural victims in race/ethnicity, marital status, country of birth, and neighborhood characteristics. After controlling for individual characteristics, the nature of the residential neighborhood environment significantly differentiates urban and rural IPFs. Conclusions: Our findings suggest a different role for neighborhood context in affecting intimate violence risk in rural settings, and that different measures may be needed to capture the qualities of rural environments that affect intimate violence risk. Our findings reinforce the argument that multilevel strategies are required to understand and reduce the burden of intimate violence, and that interventions may need to be crafted for specific geographical contexts.

Barriers to Cancer Clinical Trial Participation Among American Indian and Alaska Native Tribal College Students

Abstract: American Indians and Alaska Natives (AIs/ANs) have cancer-related mortality rates that are among the highest of all racial and ethnic groups in the US.1,2 They are also more likely to be diagnosed with late-stage cancer and to have lower 5-year survival rates than other groups.3 These pronounced disparities underscore the need for access to cancer clinical trials in this population. The National Institutes of Health recognize the importance of clinical trials for improving health care for racial and ethnic minorities, as they mandated in 1993 that all sponsored research must include women and minority groups.4 However, fewer than 3% of US cancer patients are enrolled in trials funded by the National Cancer Institute, and AI/AN patients are conspicuously underrepresented in such trials, as are other racial and ethnic groups, rural populations, and older adults generally.5–8 One study of participation in surgical oncology trials counted only 35 AI/AN participants (0.25%) out of a total sample of 13,991.9 Limited research has investigated barriers to participation in cancer clinical trials by AI/AN people. A review of articles reporting original data on recruiting barriers found that a scant 65 of 5,257 articles provided information on minority subgroups, and only 4 of these included AIs/ANs.8 A few studies of barriers to general medical care and clinical trial participation for AI/AN people have identified medical mistrust and lack of transportation as issues.10,11 In a survey of 112 AI/AN elders, we found that living far from the study site decreased willingness to participate in cancer clinical trials, as did a high risk that confidentiality would be broken. Several other factors also strongly increased willingness to participate in cancer clinical trials: research led by an investigator of AI/AN descent, research including a physician with experience treating AI/AN people, personal experience with the type of cancer studied, family support for participation, and hope that the research would provide new treatments.12 Building on these findings, we aimed to (1) identify factors that influence willingness to participate in cancer clinical trials among AI/AN students enrolled in tribal colleges, (2) develop a scale measuring willingness to participate, and (3) compare attitudes of AI/AN tribal college students to those of older AI/AN nonstudent adults. Because younger patients were over-represented in some studies of cancer clinical trials,7–9 we hypothesized that younger tribal college students might demonstrate more willingness to participate in trials than would older nonstudent adults.

Rural Relevant Quality Measures for Critical Access Hospitals

Abstract: Purpose: To identify current and future relevant quality measures for Critical Access Hospitals (CAHs). Methods: Three criteria (patient volume, internal usefulness for quality improvement, and external usefulness for public reporting and payment reform) were used to analyze quality measures for their relevance for CAHs. A 6-member panel with expertise in rural hospital quality measurement and improvement provided input regarding the final measure selection. Findings: The relevant quality measures for CAHs include measures that are ready for reporting now and measures that need specifications to be finalized and/or a data reporting mechanism to be established. They include inpatient measures for specific medical conditions, global measures that address appropriate care across multiple medical conditions, and Emergency Department measures. Conclusions: All CAHs should publicly report on relevant quality measures. Acceptance of a single consolidated set of quality measures with common specifications for CAHs by all entities involved in regulation, accreditation, and payment; a phased process to implement the relevant measures; and the provision of technical assistance would help CAHs meet the challenge of reporting.

Unintentional Injury, Psychological Distress and Depressive Symptoms: Is There an Association for Rural Australians?

Abstract: Purpose: To investigate the association between unintentional injury and mental health in Australian rural communities. Methods: Using cross-sectional baseline data for a longitudinal study from randomly selected adults in nonmetropolitan Australia, we fitted logistic regression models for the outcomes of domestic or public setting injury and injury in high-risk settings, using prior depression and demographic factors. OR and 99% CI were reported and also calculated for current mental health including psychological distress, depressive symptoms and risky alcohol consumption, comparing those injured with those not. Findings: Of 2,639 participants who completed the injury component, 364 (13.8%) reported injury requiring treatment from a doctor or a hospitalization in the previous 12 months. Of those requiring treatment or hospitalization, 147 (40.4%) reported being injured in a domestic or public setting and 207 (56.9%) in a high-risk setting. The most common types and mechanisms of injury were sprains and strains, and falls, trips and slips, respectively. Preinjury depression was independently associated with unintentional injury in a domestic or public setting. Being injured in this setting was associated with double the odds of experiencing current depressive symptoms. The likelihood of a high-risk setting injury was significantly associated with male gender. High-risk setting injury was associated with current psychological distress and higher levels of alcohol usage. Conclusions: This study supports the hypothesis that pre-existing depression is associated with unintentional injury in a rural sample and indicates the important role of prior depression in management of injury, given the high rate of injury in rural communities. Mechanisms by which prior depression increases likelihood of unintentional injury will be further investigated using longitudinal data. Language: en

A Qualitative Analysis of Provider Barriers and Solutions to HIV Testing for Substance Users in a Small, Largely Rural Southern State

Abstract: Testing is an important strategy for reducing the spread of HIV for several reasons. First, the CDC estimates that about 20% of persons with HIV in the U.S. do not know they have it so may continue to unknowingly infect others.1-3 An estimated 50% of new HIV infections are transmitted by the 20% of persons who do not know they have HIV.2,3 Second, persons who are unaware of having the disease cannot benefit from antiretroviral treatment. Third, persons who are aware of being infected are less likely to engage in HIV risk behaviors than those who are not aware.2,3 Despite the many reasons testing can be beneficial, testing rates remain low; in fact, only 55% of adults in U.S. have ever been tested,4 and the reasons for non-testing remain unclear. Integrating HIV testing programs into substance use treatment is a promising avenue to help increase access to HIV testing services for rural drug users.5-7 Yet as recently as 2009, only 36% of urban and 11% of rural outpatient substance use treatment facilities in the U.S. provided HIV testing.8 Insufficient resources and reimbursement, complex funding requirements, and differences in program philosophy or treatment paradigm are some of the barriers to incorporating routine screening for HIV into substance abuse treatment programs that have been identified in other studies.9-19 However, we do not fully understand the barriers that rural substance use treatment providers and system administrators perceive to integrating HIV testing into their programs. Existing research sheds little light on the crucially important contextual and specific processes that may inhibit or facilitate integration of HIV testing with community substance abuse treatment, especially in the rural South, where HIV is spreading rapidly.20,21 The primary purpose of this qualitative study was to identify barriers to HIV testing for substance users as described by substance use treatment and HIV testing service administrators and providers in Arkansas.

Frontier America's health system challenges and population health outcomes.

Abstract: Purpose The objective of this cross-sectional descriptive study was to examine and compare the county-level characteristics including demographic factors, health system factors, and population health outcomes of frontier and nonfrontier counties in the United States. All counties in the United States were studied using the merged County Health Rankings 2011 and the Area Resource File 2009 databases. Of a total of 3,141 counties in the County Health Rankings 2011 database, 438 were identified as frontier counties using the conventional definition of fewer than 7 persons per square mile. Findings Frontier counties were found to have a significantly higher proportion of elderly, Hispanic, and Native American residents than nonfrontier counties. Frontier counties have lower household income and lower levels of illiteracy. Frontier counties also have significantly fewer primary care physicians and higher uninsurance rates. Although frontier counties have a lower percentage of ZIP codes with healthy food and recreational facilities, the incidence of obesity is lower in frontier areas. Conclusions Empirical literature on the population health outcomes and health system factors of frontier areas is limited. Frontier communities in the United States face significant challenges in terms of having populations with a higher need for primary care such as the elderly and poor. In addition, they face access barriers due to geographic remoteness. The availability of reliable data on population outcomes will enable policy makers to monitor the health status of frontier populations and to design solutions to the access issues that these populations face.

Communication and Mass Vaccination Strategies After Pertussis Outbreak in Rural Amish Communities—Illinois, 2009–2010

Abstract: Purpose During January 2010, 2 infants from an Amish community in east-central Illinois were hospitalized with pertussis. The local health department (LDH) intervened to control disease transmission, identify contributing factors, and determine best communications methods to improve vaccination coverage. Methods A retrospective cohort study was conducted using public health surveillance data to determine the extent of the outbreak; the standard Centers for Disease Control and Prevention and Council of State and Territorial Epidemiologists case definition for pertussis was used. The standardized Illinois Department of Public Health pertussis patient interview form was used to collect demographic, symptom, vaccination history, and treatment history information. To control disease transmission, LDH staff worked with the Amish community to promote a vaccination campaign during February 6–April 30, 2010. Findings Forty-seven cases were identified, with onsets during December 2009–March 2010. Median age was 7 (interquartile range 1–12) years. Nineteen (40%) patients were male; 39 (83%) were aged <18 years; 37 (79%) had not received any pertussis-containing vaccine. Presenting symptoms did not differ substantially between vaccinated and unvaccinated patients. Duration of cough was longer among unvaccinated than vaccinated patients (32 vs 15.5 days, P = .002). Compared with vaccinated patients, proportionately more unvaccinated patients reported secondary household transmission (30% vs 72%; P = .012). Through enhanced vaccination campaigns, 251 (∼10%) Amish community members were administered 254 pertussis-containing vaccines. Conclusions Targeted health communication and outreach resulted in a successful vaccine campaign and long-running monthly vaccination clinic. Amish do not universally reject vaccines, and their practices regarding vaccination are not static.