Showing papers in "Journal of Rural Health in 2015"

Rural Healthy People 2020: New Decade, Same Challenges.

Abstract: Purpose The health of rural America is more important than ever to the health of the United States and the world. Rural Healthy People 2020's goal is to serve as a counterpart to Healthy People 2020, providing evidence of rural stakeholders’ assessment of rural health priorities and allowing national and state rural stakeholders to reflect on and measure progress in meeting those goals. The specific aim of the Rural Healthy People 2020 national survey was to identify rural health priorities from among the Healthy People 2020's (HP2020) national priorities. Methods Rural health stakeholders (n = 1,214) responded to a nationally disseminated web survey soliciting identification of the top 10 rural health priorities from among the HP2020 priorities. Stakeholders were also asked to identify objectives within each national HP2020 priority and express concerns or additional responses. Findings and Conclusions Rural health priorities have changed little in the last decade. Access to health care continues to be the most frequently identified rural health priority. Within this priority, emergency services, primary care, and insurance generate the most concern. A total of 926 respondents identified access as the no. 1 rural health priority, followed by, no. 2 nutrition and weight status (n = 661), no. 3 diabetes (n = 660), no. 4 mental health and mental disorders (n = 651), no. 5 substance abuse (n = 551), no. 6 heart disease and stroke (n = 550), no. 7 physical activity and health (n = 542), no. 8 older adults (n = 482), no. 9 maternal infant and child health (n = 449), and no. 10 tobacco use (n = 429).

Rural-urban differences in mental health, resilience, stigma, and social support among young Australian gay men.

Abstract: Purpose Depression and anxiety are common among young gay men, particularly in comparison with their heterosexual counterparts. Little is known about the mental health and well-being of those living in rural areas, where access to support and opportunities for connecting with other gay men may be relatively limited. We examined differences in the well-being of young rural and urban Australian gay men, including mental health, resilience, stigma-related challenges, and social support. Methods A national online survey was conducted involving 1,034 Australian gay-identified men aged 18-39 years. Findings All analyses adjusted for sociodemographic differences between the rural and urban samples. On average, rural men had significantly lower self-esteem, lower life satisfaction, lower social support, and were significantly more likely to be psychologically distressed, concerned about acceptance from others, and to conceal their sexual orientation compared to urban gay men. While resilience among the rural group was lower, this was no longer significant following sociodemographic adjustment. An examination of psychosocial predictors of psychological distress in the rural sample revealed that lower education and lower tangible support independently predicted greater distress. Conclusions Young rural Australian gay men appear to be at a considerable disadvantage with regard to mental health and well-being compared with their urban counterparts, and they may need particular attention in mental health prevention and treatment programs.

The Rural Obstetric Workforce in US Hospitals: Challenges and Opportunities.

Abstract: Purpose The purpose of this study was to describe the types and combinations of clinicians who are delivering babies in rural hospitals, their employment status, the relationship between hospital birth volume and staffing models, and the staffing challenges faced by rural hospitals. Methods We conducted a telephone survey of 306 rural hospitals in 9 states: Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin, from November 2013 to March 2014 to assess their obstetric workforce. Bivariate associations between hospitals’ annual birth volume and obstetric workforce characteristics were examined, as well as qualitative analysis of workforce changes and staffing challenges. Findings Hospitals with lower birth volume (<240 births per year) are more likely to have family physicians and general surgeons attending deliveries, while those with a higher birth volume more frequently have obstetricians and midwives attending deliveries. Reported staffing challenges include scheduling, training, census fluctuation, recruitment and retention, and intrahospital relationships. Conclusions Individual hospitals working in isolation may struggle to address staffing challenges. Federal and state policy makers, regional collaboratives, and health care delivery systems can facilitate solutions through programs such as telehealth, simulation training, and interprofessional education.

Rural health care bypass behavior: how community and spatial characteristics affect primary health care selection.

Abstract: Purpose (1) To assess the prevalence of rural primary care physician (PCP) bypass, a behavior in which residents travel farther than necessary to obtain health care, (2) To examine the role of community and non-health-care-related characteristics on bypass behavior, and (3) To analyze spatial bypass patterns to determine which rural communities are most affected by bypass. Methods Data came from the Montana Health Matters survey, which gathered self-reported information from Montana residents on their health care utilization, satisfaction with health care services, and community and demographic characteristics. Logistic regression and spatial analysis were used to examine the probability and spatial patterns of bypass. Results Overall, 39% of respondents bypass local health care. Similar to previous studies, dissatisfaction with local health care was found to increase the likelihood of bypass. Dissatisfaction with local shopping also increases the likelihood of bypass, while the number of friends in a community, and commonality with community reduce the likelihood of bypass. Other significant factors associated with bypass include age, income, health, and living in a highly rural community or one with high commuting flows. Conclusions Our results suggest that outshopping theory, in which patients bundle services and shopping for added convenience, extends to primary health care selection. This implies that rural health care selection is multifaceted, and that in addition to perceived satisfaction with local health care, the quality of local shopping and levels of community attachment also influence bypass behavior.

Psychotherapy Utilization Among Rural and Urban Veterans From 2007 to 2010

Abstract: Purpose This study evaluated change in rural and urban veterans’ psychotherapy use during a period of widespread effort within the Veterans Health Administration (VHA) to engage rural veterans in mental health care. Methods National VHA administrative databases were queried for patients receiving a new diagnosis of depression, anxiety, or posttraumatic stress disorder in fiscal years (FY) 2007 and 2010. Using the US Department of Agriculture Rural-Urban Continuum Codes, we identified urban (FY 2007: n = 192,347; FY 2010: n = 231,471) and rural (FY 2007: n = 72,923; FY 2010: n = 81,905) veterans. Veterans’ psychotherapy use during the 12 months following diagnosis was assessed. Findings From FY 2007 to 2010, the proportion of veterans receiving any psychotherapy increased from 17% to 22% for rural veterans and 24% to 28% for urban veterans. Rural veterans were less likely to receive psychotherapy across both fiscal years; however, the magnitude of this disparity decreased significantly from 2007 (odds ratio [OR] = 1.51) to 2010 (OR = 1.41). Similarly, although urban veterans received more psychotherapy sessions, urban-rural disparities in the receipt of 8 or more psychotherapy sessions decreased over the study period (2007: OR = 2.32; 2010: OR = 1.69). Conclusions Rural and urban veterans are increasingly making use of psychotherapy, and rural-urban gaps in psychotherapy use are shrinking. These improvements suggest that recent VHA efforts to engage rural veterans in care have been successful at reducing differences between rural and urban veterans with respect to access and engagement in psychotherapy.

Cancer Survivorship in Rural and Urban Adults: A Descriptive and Mixed Methods Study

Abstract: Purpose Rural-dwelling cancer survivors (CSs) are at risk for decrements in health and well-being due to decreased access to health care and support resources. This study compares the impact of cancer in rural- and urban-dwelling adult CSs living in 2 regions of the Pacific Northwest. Methods A convenience sample of posttreatment adult CSs (N = 132) completed the Impact of Cancer version 2 (IOCv2) and the Memorial Symptom Assessment Scale-short form. High and low scorers on the IOCv2 participated in an in-depth interview (n = 19). Findings The sample was predominantly middle-aged (mean age 58) and female (84%). Mean time since treatment completion was 6.7 years. Cancer diagnoses represented included breast (56%), gynecologic (9%), lymphoma (8%), head and neck (6%), and colorectal (5%). Comparisons across geographic regions show statistically significant differences in body concerns, worry, negative impact, and employment concerns. Rural-urban differences from interview data include access to health care, care coordination, connecting/community, thinking about death and dying, public/private journey, and advocacy. Conclusion The insights into the differences and similarities between rural and urban CSs challenge the prevalent assumptions about rural-dwelling CSs and their risk for negative outcomes. A common theme across the study findings was community. Access to health care may not be the driver of the survivorship experience. Findings can influence health care providers and survivorship program development, building on the strengths of both rural and urban living and the engagement of the survivorship community.

Fatalistic Beliefs and Completion of the HPV Vaccination Series Among a Sample of Young Appalachian Kentucky Women

Abstract: Human papillomavirus (HPV) is the most prevalent sexually transmitted infection in the United States, affecting an estimated 79 million individuals.1 High-risk HPV types are associated with various cancers, with HPV types 16 and 18 causing an estimated two-thirds of all cervical cancers.1 Two vaccines (HPV4, Gardasil®; HPV2, Cervarix®) are now widely available for the primary prevention of HPV infection and cervical cancer.2 The Centers for Disease Control and Prevention (CDC) recommends routine HPV vaccination for females ages 11–12 and catch-up vaccination for females ages 13–26. Current CDC guidelines recommend that the second dose of the HPV vaccine series be administed 1–2 months after the first injection; the third dose is administered 6 months after the first dose.3 Unfortunately, HPV vaccination rates remain below Healthy People 2020 targets, especially among young adult women and in regions of the country that may need this cancer prevention strategy the most, including Appalachia.4–6 Lower HPV vaccination rates in Appalachia are problematic considering the higher prevalence of high-risk HPV infection and cervical cancer incidence and mortality rates in that region.7–11 Barriers to the initial uptake and eventual completion of the 3-dose HPV vaccine series among Appalachian women have been previously documented, with the high monetary cost of vaccination serving as a primary barrier.12–14 However, Crosby et al found that even when the barrier of cost was removed, young women residing in rural Appalachian Kentucky were less likely than their urban counterparts to accept and complete HPV vaccination.5 This finding suggests that factors unrelated to cost may serve as important barriers to HPV vaccination behaviors. Other noted barriers to HPV vaccination among Appalachian women include lack of transportation, limited parental/peer/health care provider support, cultural views, and lack of knowledge regarding cervical cancer prevention and HPV.13,15–17 There is an additional barrier to preventive cancer behavior, however, that has received limited attention as it relates to HPV vaccination, and that is the concept of fatalism. Fatalism has been examined as a potential determinant for engaging in preventive cancer strategies, including cancer information seeking, screening (eg, colorectal cancer screening, Papanicolaou [Pap] testing, mammography) and preventive behaviors (eg, diet, exercise, smoking).18–22 Although the definition of fatalism varies across studies and disciplines, the concept is often operationalized as mortality from cancer being inevitable and that the disease is beyond an individual’s personal control.19,23–25 Indeed, fatalistic beliefs have been previously identified as barriers to cancer prevention and screening among racial/ethnic minorities, individuals of lower socioeconomic status, the elderly, rural populations, and Appalachians.23,25–33 However, there has been limited research on the potential impact of fatalistic beliefs on HPV vaccination behaviors as a preventive cancer strategy, specifically among young Appalachian adults.13,34 Therefore, the purpose of this study was to examine whether fatalistic beliefs were associated with completion of the full HPV vaccine series among young women in Appalachian Kentucky.

Predictors of Colorectal Cancer Screening: Does Rurality Play a Role?

Abstract: Purpose The purpose of this study was to explore the associations between sociodemographic factors such as residence, health care access, and colorectal cancer (CRC) screening among residents of Texas. Methods Using the 2012 Behavioral Risk Factor Surveillance Survey, we performed logistic regression analyses to determine predictors of CRC screening among Texas residents, including rural versus urban differences. Our outcomes of interest were previous (1) CRC screening using any CRC test, (2) fecal occult blood test (FOBT), or (3) endoscopy, as well as up-to-date screening using (4) any CRC test, (5) FOBT, or (6) endoscopy. The independent variable of interest was rural versus urban residence; we controlled for other sociodemographic and health care access variables such as lack of health insurance. Results Multivariate analysis showed that individuals who were residents of a rural/non-Metropolitan Statistical Area (MSA) location (OR = 0.70, 95% CI = 0.51-0.97) or a suburban county (OR = 0.61, 95% CI = 0.39-0.95) were less likely to report ever having any CRC screening compared to residents of a center city of an MSA. Residents of a rural/non-MSA location were less likely (OR = 0.49, 95% CI = 0.28-0.87) than residents of a center city of an MSA to be up-to-date using FOBT. There was decreased likelihood of ever being screened for CRC among the uninsured (OR = 0.43, 95% CI = 0.31-0.59). Conclusions Effective development and implementation of strategies to improve screening rates should aim at improving access to health care, taking into account demographic characteristics such as rural versus urban residence.

Disparities in the Utilization of Laparoscopic Surgery for Colon Cancer in Rural Nebraska: A Call for Placement and Training of Rural General Surgeons.

Abstract: Background Advances in medical technology are changing surgical standards for colon cancer treatment. The laparoscopic colectomy is equivalent to the standard open colectomy while providing additional benefits. It is currently unknown what factors influence utilization of laparoscopic surgery in rural areas and if treatment disparities exist. The objectives of this study were to examine demographic and clinical characteristics associated with receiving laparoscopic colectomy and to examine the differences between rural and urban patients who received either procedure. Methods This study utilized a linked data set of Nebraska Cancer Registry and hospital discharge data on colon cancer patients diagnosed and treated in the entire state of Nebraska from 2008 to 2011 (N = 1,062). Multiple logistic regression analysis was performed to identify predictors of receiving the laparoscopic treatment. Results Rural colon cancer patients were 40% less likely to receive laparoscopic colectomy compared to urban patients. Independent predictors of receiving laparoscopic colectomy were younger age (<60), urban residence, ≥3 comorbidities, elective admission, smaller tumor size, and early stage at diagnosis. Additionally, rural patients varied demographically compared to urban patients. Conclusions Laparoscopic surgery is becoming the new standard of treatment for colon cancer and important disparities exist for rural cancer patients in accessing the specialized treatment. As cancer treatment becomes more specialized, the importance of training and placement of general surgeons in rural communities must be a priority for health care planning and professional training institutions.

Human papillomavirus vaccine awareness, uptake, and parental and health care provider communication among 11- to 18-year-old adolescents in a rural Appalachian Ohio county in the United States.

Abstract: Purpose This study examined human papillomavirus (HPV) vaccine awareness and uptake, and communication with a parent and/or a health care provider among 11- to 18-year-old male and female adolescents in an Appalachian Ohio county. Methods Five questions regarding the HPV vaccine were added to the 2012 Youth Risk Behavior Surveillance System (YRBSS) surveys administered to middle and high school students in the county. The YRBSS surveys are school-based, anonymous, and voluntary. The questions added were about vaccine awareness and uptake, and communication with a parent or health care provider about the vaccine. Results Of the 1,299 participants, 51.9% were male and 90.3% were white. Overall, 49.2%, 23.5%, 19.2%, and 24.6%, respectively, reported vaccine awareness, uptake of at least 1 dose of the HPV vaccine, communication with a parent, and communication with a health care provider. Females and adolescents ≥15 years were significantly more likely to report awareness, uptake, and parental and provider communication than males and adolescents ≤14 years. Adolescents receiving any dose of the vaccine were significantly more likely to have had a parent (OR: 3.74; 95% CI: 2.30-6.06) or a health care provider (OR: 10.91; 95% CI: 6.42-18.6) discuss the vaccine than those who had not received any dose. Conclusions Despite the strong link between parental and health care provider communication and HPV vaccine uptake, the levels of communication remain low in this Appalachian population. These findings suggest the need for public health education programs targeting the health care providers, the parents, and the adolescents to improve awareness, knowledge, and HPV vaccine uptake.

Rural/Urban Residence, Access, and Perceived Need for Treatment Among African American Cocaine Users

Abstract: Overall illicit drug use remains slightly higher in urban than rural counties, but it clearly is no longer an exclusively urban phenomenon,1 raising concerns about rural access to drug use treatment services. Many policy makers, researchers, and treatment providers presume that access to drug use treatment is worse in rural areas, but a review of the extant literature revealed that very little information exists on this issue.2 One study found that drug users residing in a single urban area were twice as likely to receive treatment as compared to those from a single rural area of Florida.3 A unique longitudinal study of at-risk rural and urban drinkers residing in 6 southern states found in bivariate analyses that rural at-risk drinkers had greater use of help for their drinking, more use of psychiatrists, and more use of inpatient, outpatient, and ER treatment than their urban counterparts.4 However, these differences did not remain when adjusting for demographic, social, and economic factors. The extant literature also offers very little information about rural or urban residents’ perceptions of the accessibility of substance use treatment. The longitudinal study of at-risk drinkers mentioned earlier found no significant rural vs urban differences in perceptions of waiting times, the acceptability of formal treatment for alcohol problems, and privacy concerns.4,5 Evidence from the broader mental health literature may lend some insight into potential rural/urban differences. For example, depressed persons living in rural areas have been found to have worse perceptions of the availability, accessibility, and acceptability of specialty mental health services than their urban counterparts.6 Related to actual treatment utilization is perceived need for treatment. Conceptually, perceiving a need for treatment reflects recognition of a drug use problem and a belief that treatment will help.7-11 Thus, it is arguably an essential “first step” in making the decision to seek treatment, at least among persons who are not mandated into treatment by the legal system.8,12 In fact, prior research suggests a strong association between perceived need and actual drug use treatment attendance.7,13,14 Perceived need has also been linked to remaining in substance use treatment and positive treatment outcomes.15,16 Despite the relevance of studying perceived need to advance our understanding of treatment-seeking decisions, few studies have examined the factors that promote or impede perceived need for drug, alcohol, or mental health services.7,10,12 Even less research has focused specifically on perceived need for drug use treatment, with the notable exception of a 3-state study of rural stimulant users which found that prior substance use treatment, family and social problems, and legal problems resulting from drug use were positively associated with perceived need.8 African American cocaine users residing in rural areas of the southern US may be at particularly high risk for low perceived need for treatment. According to data from the National Survey on Drug Use and Health (NSDUH), the lifetime prevalence of crack cocaine use is higher among African Americans age 18 years and older than among every other racial/ethnic group except persons reporting 2 or more races.17 The NSDUH also showed that only 2.8% of African Americans age 12 years and older who satisfy criteria for a drug use disorder think they need and actually attempt to seek treatment.18 Lastly, the multi-state study of rural stimulant users mentioned earlier found heavy cocaine use and low rates of treatment among mostly African American participants in the southern state of Arkansas.13,19,20 A better understanding of the factors associated with African American cocaine users’ perceived need for treatment could enable health policy makers, managers, and providers to make more informed decisions about the targeting and tailoring of programs aimed at increasing treatment uptake. Andersen's Behavioral Model of Health Services has been frequently used to identify the predisposing, enabling, and need/health status factors that explain health services utilization,21 including substance use treatment.13 Predisposing factors, such as demographics, are considered largely immutable but can be used to identify subgroups of persons at risk for inadequate utilization or, in the case of this study, perceived need for treatment. Enabling social and economic factors, such as health insurance and rural/urban residence, are thought to affect individuals’ ability to obtain services. Enabling access factors are sometimes distinguished from other enabling indicators because they are more modifiable by institutional or policy-level changes.22 Finally, health is typically assessed by self-reports or a clinical diagnosis and is theorized to have the strongest association with health services use. The study's primary purpose was to examine how rural/urban residence and other predisposing, enabling, and health status factors are associated with perceived need for drug use treatment. A secondary purpose was to compare and contrast rural and urban drug users’ perceived access to drug use treatment. Because prior research suggests that rural residents less frequently utilize substance use services,3,4 we hypothesized that they would have lower perceived need. To address these study questions, we conducted a population-based study of not-in-treatment African American cocaine users residing in rural and urban areas of Arkansas.

Perspectives of Behavioral Health Clinicians in a Rural Integrated Primary Care/Mental Health Program

Abstract: Purpose This study compares the perspectives of rural and urban mental health clinicians working in various Washington State Community Health Centers that have implemented an integrated primary care/mental health program. Methods We conducted a Web-based survey of mental health clinicians (n = 71) who work in an integrated primary care/mental health program (“the program”) in 1 of 150 safety net primary care clinics in Washington State. Most participating clinics are Federally Qualified Health Centers or Rural Health Clinics. Pooled survey results from clinicians working in rural settings were compared to those working in urban settings. Semistructured interviews were conducted with a subset (n = 32) of survey respondents. Comments made during these interviews were analyzed for themes. Findings In the survey phase, both rural and urban clinicians generally agreed that the program benefitted their patients. Rural respondents were particularly appreciative of the flexibility that the program offered when planning care. Not surprisingly, social service limitations (such as housing or transportation services) were more often mentioned as program limitations. Rural clinicians were more likely to note a lack of awareness of program resources among other medical providers on the team. Conclusions Clinicians working in rural primary care clinics value the availability and flexibility of an integrated primary care/mental health program as an option for providing mental health care for their patients. Clinicians working in rural settings could benefit from additional training and program implementation support to best meet the needs of their patients.

Health information technology workforce needs of rural primary care practices.

Abstract: Purpose This study assessed electronic health record (EHR) and health information technology (HIT) workforce resources needed by rural primary care practices, and their workforce-related barriers to implementing and using EHRs and HIT. Methods Rural primary care practices (1,772) in 13 states (34.2% response) were surveyed in 2012 using mailed and Web-based questionnaires. Findings EHRs or HIT were used by 70% of respondents. Among practices using or intending to use the technology, most did not plan to hire new employees to obtain EHR/HIT skills and even fewer planned to hire consultants or vendors to fill gaps. Many practices had staff with some basic/entry, intermediate and/or advanced-level skills, but nearly two-thirds (61.4%) needed more staff training. Affordable access to vendors/consultants who understand their needs and availability of community college and baccalaureate-level training were the workforce-related barriers cited by the highest percentages of respondents. Accessing the Web/Internet challenged nearly a quarter of practices in isolated rural areas, and nearly a fifth in small rural areas. Finding relevant vendors/consultants and qualified staff were greater barriers in small and isolated rural areas than in large rural areas. Discussion/Conclusions Rural primary care practices mainly will rely on existing staff for continued implementation and use of EHR/HIT systems. Infrastructure and workforce-related barriers remain and must be overcome before practices can fully manage patient populations and exchange patient information among care system partners. Efforts to monitor adoption of these skills and ongoing support for continuing education will likely benefit rural populations.

Sociodemographic and Environmental Correlates of Active Commuting in Rural America

Abstract: PURPOSE: This research investigated participation rates in 3 modes of active commuting (AC) and their sociodemographic and physical environmental correlates in rural America. METHODS: The 2000 Census supplemented with other data sets were used to analyze AC rates in percentage of workers walking, biking, and taking public transportation to work in 14,209 nonmetropolitan rural tracts identified by RUCA codes, including 4,067 small rural and 10,142 town-micropolitan rural tracts. Sociodemographic and physical environmental variables were correlated with 3 AC modes simultaneously using Seemingly Unrelated Regression for nonmetro rural, and for small rural and town-micropolitan rural separately. FINDINGS: The average AC rates in rural tracts were 3.63%, 0.26%, and 0.56% for walking, biking, and public transportation to work, respectively, with small rural tracts having a higher rate of walking but lower rates of biking and public transportation to work than town-micropolitan tracts. In general, better economic well-being was negatively associated with AC but percentage of college-educated was a positive correlate. Population density was positively associated with AC but greenness and proximity to parks were negative correlates. However, significant differences existed for different AC modes, and between small rural and town-micropolitan rural tracts. CONCLUSIONS: Sociodemographic factors explained more variance in AC than physical environmental factors but the detailed relationships were complex, varying by AC mode and by degree of rurality. Any strategy to promote AC in rural America needs to be sensitive to the population size of the area and assessed in a comprehensive manner to avoid a "one size fits all" approach. Language: en

A Comparison of the J-1 Visa Waiver and Loan Repayment Programs in the Recruitment and Retention of Physicians in Rural Nebraska.

Abstract: Purpose There is a dearth of literature evaluating the effectiveness of programs aimed at recruiting and retaining physicians in rural Nebraska. Taking advantage of the Nebraska Health Professional Tracking System, this study attempts to comparatively assess the effectiveness of the J-1 visa waiver and state loan repayment programs in the recruitment and retention of physicians in rural Nebraska. Methods A mixed methods approach was used. We tracked 240 physicians who enrolled in the J-1 visa waiver and state loan repayment programs between 1996 and 2012 until 2013. In addition, key informant interviews were conducted to obtain perspectives on the recruitment and retention of physicians in rural Nebraska through the 2 programs. Findings Results from multilevel survival regression analysis indicated that physicians enrolled in the J-1 visa waiver program were more likely to leave rural Nebraska when compared with those enrolled in the state loan repayment program. Participants in the qualitative study, however, cautioned against declaring one program as superior over the other, given that the 2 programs addressed different needs for different communities. In addition, results suggested that fostering the integration of physicians and their families into rural communities might be a way of enhancing retention, regardless of program. Conclusion The findings from this study highlight the complexity of recruitment and retention issues in rural Nebraska and suggest the need for more holistic and family-centered approaches to addressing these issues.

Warfarin Treatment and Outcomes of Patients With Atrial Fibrillation in Rural and Urban Settings

Abstract: Background Warfarin is an effective agent in the prevention of stroke in patients with atrial fibrillation (AF). However, it requires close monitoring with regular visits to health care facilities. To date, it is unknown whether there is a difference in warfarin utilization and outcomes between urban and rural settings. Methods We used administrative databases to compare warfarin utilization patterns and stroke and major bleeding outcomes in rural and urban settings in a population-based cohort study of patients ≥ 65 years admitted to hospital with a diagnosis of AF in the province of Quebec, Canada, from 1999 to 2007. Patients’ postal codes were used to differentiate between rural and urban settings. Results The cohort comprised 18,198 rural (21.8%) and 65,315 urban (78.2%) patients, with similar mean age of 79 years and a similar burden of comorbidities. Overall, there was marked underutilization of warfarin in both rural and urban settings. Warfarin-filled prescription rates were slightly higher in the rural setting (adjusted OR: 1.16, 95% CI: 1.12-1.20). In multivariable Cox regression analyses, the risk for stroke and major bleeding in rural settings was similar to that in urban settings (stroke: adjusted HR: 1.01, 95% CI: 0.95-1.09; major bleeding: adjusted HR: 1.03, 95% CI: 0.95-1.12). Conclusions Patients in rural settings were slightly more likely to fill a prescription for warfarin, but they experienced similar stroke and major bleeding rates to their urban counterparts.

Receipt of Regular Primary Care and Early Cancer Detection in Appalachia.

Abstract: Purpose The objective was to examine the impact of regular primary care encounters (PCE) on early breast cancer detection in an Appalachian sample of Medicare beneficiaries diagnosed 2006-2008. Determinants of PCE were investigated and a mediation analysis was conducted where PCE was a mediator to cancer stage. Methods A total of 3,589 cases were identified from Appalachian areas in Pennsylvania, Kentucky, Ohio, and North Carolina, and health care services were examined 2 months to 2 years prior to diagnosis. A regular care PCE variable was constructed with 4 ordinal levels: none, any, “annual,” and “semi-annual.” Association of PCE with stage, mortality and covariables was conducted using ordinal logistic regressions and Cox Proportional Hazards survival models. Results Sixty-eight percent of the cases had semi-annual PCE. Regular PCE was strongly associated with late-stage cancer rates (39%-13% by increasing PCE level, P < .0001) and 5-year all-cause mortality (42%-24%, P < .0001). Subgroup analysis revealed variations by hypertension and urban status, with nonhypertensives with no PCE being at particularly increased risk. Significant determinants of PCE included age, rural/urban status, comorbidity, dual Medicaid insurance, Appalachian region economic classification, state, select comorbidities, hypertension, and minimum distance to provider. Mediation analysis results were consistent with lower number of comorbidities leading to increased late cancer detection due to patients having a decreased PCE. Conclusion PCE is an important determinant of cancer detection, with a dose-response relationship. Variations exist by geography and hypertension. Comorbidity may influence both PCE and late-stage rates with partial mediation through PCE.

A Controlled Community‐Based Trial to Promote Smoke‐Free Policy in Rural Communities

Abstract: Purpose Rural, tobacco-growing areas are disproportionately affected by tobacco use, secondhand smoke, and weak tobacco control policies. The purpose was to test the effects of a stage-specific, tailored policy-focused intervention on readiness for smoke-free policy, and policy outcomes in rural underserved communities. Methods A controlled community-based trial including 37 rural counties. Data were collected annually with community advocates (n = 330) and elected officials (n = 158) in 19 intervention counties and 18 comparison counties over 5 years (average response rate = 68%). Intervention communities received policy development strategies from community advisors tailored to their stage of readiness and designed to build capacity, build demand, and translate and disseminate science. Policy outcomes were tracked over 5 years. Findings Communities receiving the stage-specific, tailored intervention had higher overall community readiness scores and better policy outcomes than the comparison counties, controlling for county-level smoking rate, population size, and education. Nearly one-third of the intervention counties adopted smoke-free laws covering restaurants, bars, and all workplaces compared to none of the comparison counties. Conclusions The stage-specific, tailored policy-focused intervention acted as a value-added resource to local smoke-free campaigns by promoting readiness for policy, as well as actual policy change in rural communities. Although actual policy change and percent covered by the policies were modest, these areas need additional resources and efforts to build capacity, build demand, and translate and disseminate science in order to accelerate smoke-free policy change and reduce the enormous toll from tobacco in these high-risk communities.

Evaluating tablet computers as a survey tool in rural communities.

Abstract: Purpose Although tablet computers offer advantages in data collection over traditional paper-and-pencil methods, little research has examined whether the 2 formats yield similar responses, especially with underserved populations. We compared the 2 survey formats and tested whether participants’ responses to common health questionnaires or perceptions of usability differed by survey format. We also tested whether we could replicate established paper-and-pencil findings via tablet computer.

A comparison of health, health behavior, and access between farm and nonfarm populations in rural New York state

Abstract: Background Recent technological and demographic changes in US agriculture raise questions about whether the previously observed benefits of the agricultural lifestyle persist. Methods In 2009, researchers conducted a household survey of 9,612 adults (aged 20+) in a rural region of Upstate New York. Data on health status, health behaviors, and health care access among farmers and rural nonfarm residents were compared. Results After adjustment for age, gender, education, and having a regular health care provider, male farmers had elevated prevalence of asthma (OR: 1.82, 95% CI: 1.05-3.16) and untreated chronic obstructive pulmonary disease (COPD) (OR: 3.17, 95% CI: 1.12-9.01). Farmers had significantly lower hypercholesterolemia (OR: 0.70, 95% CI: 0.50-0.99), but not lower prevalence of heart disease or stroke. Farmers had lower rates of smoking (OR: 0.60, 95% CI: 0.40-0.89) and higher rates of hard physical labor (OR: 2.61, 95% CI: 1.83-3.72) than nonfarmers, but they had notably worse health behavior prevalence relative to various types of screening, vaccinations, and having a regular medical care provider (OR: 0.53, 95% CI: 0.39-0.71). Conclusions The farm population is becoming more like the rural nonfarm population with regard to health outcomes and lifestyle, yet it remains notably poorer with regard to prevention. Targeted outreach is needed to increase prevention within the agricultural community.

Urban and Rural Differences in Parental Attitudes About Influenza Vaccination and Vaccine Delivery Models.

Abstract: Objectives To assess and compare among parents of healthy children in urban and rural areas: (1) reported influenza vaccination status; (2) attitudes regarding influenza vaccination; and (3) attitudes about collaborative models for influenza vaccination delivery involving practices and public health departments. Methods A mail survey to random samples of parents from 2 urban and 2 rural private practices in Colorado from April 2012 to June 2012. Results The response rate was 58% (288/500). In the prior season, 63% of urban and 41% of rural parents reported their child received influenza vaccination (P < .001). No differences in attitudes about influenza infection or vaccination between urban and rural parents were found, with 75% of urban and 73% of rural parents agreeing their child should receive an influenza vaccine every year (P = .71). High proportions reported willingness to participate in a collaborative clinic in a community setting (59% urban, 70% rural, P = .05) or at their child's provider (73% urban, 73% rural, P = .99) with public health department assisting. Fewer (36% urban, 53% rural, P < .01) were likely to go to the public health department if referred by their provider. Rural parents were more willing for their child to receive vaccination outside of their provider's office (70% vs. 55%, P = .01). Conclusions While attitudes regarding influenza vaccination were similar, rural children were much less likely to have received vaccination. Most parents were amenable to collaborative models of influenza vaccination delivery, but rural parents were more comfortable with influenza vaccination outside their provider's office, suggesting that other venues for influenza vaccination in rural settings should be promoted.

Validity of Medical Student Questionnaire Data in Prediction of Rural Practice Choice and Its Association With Service Orientation

Abstract: Purpose The validity of medical student projection of, and predictors for, rural practice and the association of a measure of service orientation, projected practice accessibility to the indigent, were investigated. Methods West Virginia (WV) medical student online pre- and postrural rotation questionnaire data were collected during the time period 2001-2009. Of the 1,517 respondent students, submissions by 1,271 met the time interval criterion for inclusion in analyses. Subsequent WV licensing data were available for 461 in 2013. These 2 databases were used to assess for validity of projection of rural practice, for predictors of rural practice, and for student projected accessibility of the future practice to indigent patients. Findings There were statistically significant associations between both pre- and postrotation projections of rural practice and subsequent rural practice. The most significant independent predictors of rural practice were student rural background, reported primary care intent, prediction of rural practice and projection of greater accessibility of the future practice to indigent patients. For scoring of practice access, there were trends for higher scoring by rural students and rural practitioners, with greater pre-post increases for those with urban hometowns. Conclusions This study demonstrates the utility of medical student questionnaires for projections of numbers of future rural physicians. It suggests that students with a rural background, rural practice intent, or greater service orientation are more likely to enter rural practice. It also suggests that students, particularly those with urban hometowns, are influenced by rural rotation experiences in forecasting greater practice accessibility and in entering rural practice.

Unclaimed health care benefits: a mixed-method analysis of rural veterans.

Abstract: Purpose Rural areas contribute a disproportionate number of US military recruits compared to urban areas. However, few studies have examined why many rural veterans do not enroll in the Veterans Health Administration (VHA) for health care. Our objective was to elicit reasons rural veterans chose not to use VHA. Methods This mixed-methods study included quantitative survey and qualitative interview data. Surveys were mailed to 4,176 households with a registered voter in a rural Midwestern county to reach the estimated 1,100 veterans, of whom 600 were not enrolled in VHA. Surveys were designed to assess demographics and basic eligibility requirements for VHA. Themes were derived deductively from survey responses and inductively as they emerged through analysis of interview transcripts. Findings A total of 180 veterans completed the survey and 165 were eligible based on an approximation of enrollment criteria. Of those, 74 (45%) were current VHA users, and 91 (55%) were nonusers of VHA but appeared to be eligible. The most common reason selected by these potentially eligible veterans for not using VHA was they did not think they were eligible (41%). Interviews revealed the issue of distance was superseded by the perception that enrollees must be poor and have experienced combat, injury, or disability during service. Most reported they had never been told about VHA health care benefits. Conclusions Results suggest that lack of awareness of VHA health care benefits may be the biggest barrier identified by rural veterans. Targeted outreach and education efforts related to eligibility for rural veterans are warranted.

Characteristics of Work- and Non-work-Related Farm Injuries.

Abstract: PURPOSE: Farm-related injuries are an important public health problem in agriculture because of their impact on individuals, families, and farm operations. While surveillance programs such as the Census of Fatal Occupational Injuries is available to track fatal agricultural injuries, more work is needed to examine the burden of nonfatal agricultural injuries. METHODS: Data involving agricultural injuries were collected from the Iowa Trauma Registry from January 1, 2005, through December 31, 2011. A total of 2,490 trauma patients were found to have been classified as having a farm-related injury. These nonfatal farm-related injuries were compared by work-relatedness, injury severity score, length of hospital stay, and hospital discharge status. Also reported are the age and gender of the trauma patients, as well as the population of the county in which the injury occurred. RESULTS: In our analysis, we found that work- versus nonwork-relatedness had little effect on injury severity, but that work-related injuries did result in longer average hospital stays. Injuries occurring in counties of lower population size tended to be slightly more severe and be more likely to have nonroutine discharges. CONCLUSIONS: Farm environments pose hazards which are persistent for those working and living on the farm, regardless of whether or not they are engaged in work-related activities. Public health prevention approaches that consider work and nonwork farm environments may be helpful in designing interventions to reduce injury. Language: en

Distance as a predictor of treatment attendance in a family based pediatric weight management program in rural areas.

Abstract: Purpose The primary aim of this study was to determine whether demographic variables and distance to treatment were significant predictors of treatment attendance in a family based healthy lifestyle intervention program held in rural counties. Methods Two hundred forty-nine children aged 8-12 who were overweight or obese and their parents participated in a 21-session healthy lifestyle intervention. Measures were obtained at baseline, and attendance included the number of the first core 12 sessions attended. Hierarchical linear regression analyses were conducted to identify variables that significantly predicted treatment attendance, and exploratory moderation analyses were conducted to examine if demographic variables moderated effects of distance to treatment site predicting group attendance. Findings Results support significant inverse relationships between distance to treatment and treatment attendance. Additionally, parents’ marriage status significantly moderated the relationship between distance to treatment and treatment attendance. Conclusions These results expand the literature to a rural sample and indicate the importance of marital status for treatment attendance. Knowledge of these barriers to treatment provides information to tailor interventions to improve attendance in the future. Possible strategies include addressing cultural norms, providing resources to overcome time and travel barriers, and implementing e-health interventions.

Fatalism moderates the relationship between family history of cardiovascular disease and engagement in health-promoting behaviors among at-risk rural Kentuckians.

Abstract: Purpose In rural communities that experience high rates of cardiovascular disease (CVD) morbidity and mortality, family history education may enhance risk awareness and support engagement in healthy behaviors but could also engender fatalism. This study was conducted to assess if the relationship between family history and adherence to healthy lifestyle behaviors is moderated by fatalism. Methods Baseline data were obtained from 1,027 adult participants in the HeartHealth in Rural Kentucky study. Multiple linear regression was used to determine whether fatalism moderated the relationship between high-risk family history of CVD and adherence to healthy lifestyle behaviors, controlling for sociodemographic variables and CVD risk factors. The relationship between family history and healthy behaviors was assessed for subgroups of participants divided according to the upper and lower quartiles of fatalism score. Findings The relationship between high-risk family history of CVD and adherence to healthy behaviors was moderated by fatalism. Among those with the highest quartile of fatalism scores, high-risk family history predicted greater adherence to healthy behaviors, while among those in the lowest quartile, and among those with the middle 50% of fatalism scores, there was no association between family history and healthy behavior scores. Conclusions Family history education can provide people at increased risk for CVD important information to guide health practices. This may be particularly relevant for those with a high degree of fatalistic thinking. In rural communities with limited health resources, family history education, combined with assessment of fatalism, may support better targeted interventions to enhance engagement in healthy behaviors.

Residents’ Willingness-to-Pay for Attributes of Rural Health Care Facilities

Abstract: Context As today's rural hospitals have struggled with financial sustainability for the past 2 decades, it is critical to understand their value relative to alternatives, such as rural health clinics and private practices. Purpose To estimate the willingness-to-pay for specific attributes of rural health care facilities in rural Kentucky to determine which services and operational characteristics are most valued by rural residents. Methodology We fitted choice experiment data from 769 respondents in 10 rural Kentucky counties to a conditional logit model and used the results to estimate willingness-to-pay for attributes in several categories, including hours open, types of insurance accepted, and availability of health care professionals and specialized care. Findings Acceptance of Medicaid/Medicare with use of a sliding fee scale versus acceptance of only private insurance was the most valued attribute. Presence of full diagnostic services, an emergency room, and 24-hour/7-day-per-week access were also highly valued. Conversely, the presence of specialized care, such as physical therapy, cancer care, or dialysis, was not valued. In total, respondents were willing to pay $225 more annually to support a hospital relative to a rural health clinic. Conclusion Rural Kentuckians value the services, convenience, and security that rural hospitals offer, though they are not willing to pay more for specialized care that may be available in larger medical treatment centers. The results also inform which attributes might be added to existing rural health facilities to make them more valuable to local residents.

Exploring Diversity in Socioeconomic Inequalities in Health Among Rural Dwelling Canadians

Abstract: Purpose To describe the patterning of socioeconomic inequalities in health among rural dwelling women and men in a Canadian province, exploring diversity in associations by measure of socioeconomic position, health outcome, and demographic characteristics. Methods Baseline data from the Saskatchewan Rural Health Study was used, an ongoing prospective cohort study examining the health of rural people in Saskatchewan, Canada. Of the 11,004 eligible addresses, responses to mailed questionnaires were obtained from 4,624 (42%) households, representing 8,261 women and men. Multiple logistic regression was the primary method of analysis; generalized estimating equations were utilized to account for household clustering. Associations between 5 health outcomes (self-rated health, chronic obstructive lung disease, diabetes, heart attack, high blood pressure) and 4 indicators of socioeconomic position (income, education, financial strain, occupational skill level) were assessed, with age and gender as potential effect modifiers. Findings With the exception of occupational skill level, socioeconomic position (SEP) indicators were strongly and inversely related to most health outcomes, often in a graded manner. Associations between SEP and several health outcomes were weaker for older than younger participants (heart attack, high blood pressure, lung disease) and stronger among women compared to men (high blood pressure, lung disease). Conclusions The patterning of SEP-health associations observed in this rural Canadian sample suggests the need for health promotion strategies and policy initiatives to be broadly targeted at individuals and families occupying a wide range of socioeconomic circumstances.

Shifting the Paradigm: An Assessment of the Quality of Fall Risk Reduction in Nebraska Hospitals

Abstract: PURPOSE: To assess the prevalence of evidence-based fall risk reduction structures and processes in Nebraska hospitals; whether fall rates are associated with specific structures and processes; and whether fall risk reduction structures, processes, and outcomes vary by hospital type-Critical Access Hospital (CAH) versus non-CAH. METHODS: A cross-sectional survey of Nebraska's 83 general community hospitals, 78% of which are CAHs. We used a negative binomial rate model to estimate fall rates while adjusting for hospital volume (patient days) and the exact Pearson chi-square test to determine associations between hospital type and the structure and process of fall risk reduction. FINDINGS: Approximately two-thirds or more of 70 hospitals used 6 of 9 evidence-based universal fall risk reduction interventions; 50% or more used 14 of 16 evidence-based targeted interventions. After adjusting for hospital volume, hospitals in which teams integrated evidence from multiple disciplines and reflected upon data and modified polices/procedures based upon data had significantly lower total and injurious fall rates per 1,000 patient days than hospitals that did not. Non-CAHs were significantly more likely than CAHs to perform 5 organizational-level fall risk reduction processes. CAHs reported significantly greater total (5.9 vs 4.0) and injurious (1.7 vs 0.9) fall rates per 1,000 patient days than did non-CAHs. CONCLUSIONS: Hospital type was a significant predictor of fall rates. However, shifting the paradigm for fall risk reduction from a nursing-centric approach to one in which teams implement evidence-based practices and learn from data may decrease fall risk regardless of hospital type. Language: en

Variation in Utilization of Health Care Services for Rural VA Enrollees With Mental Health-Related Diagnoses.

Abstract: Purpose Rural-dwelling Department of Veterans Affairs (VA) enrollees are at high risk for a wide variety of mental health-related disorders. The objective of this study is to examine the variation in the types of mental and nonmental health services received by rural VA enrollees who have a mental health-related diagnosis. Methods The Andersen and Aday behavioral model of health services use and the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey (MEPS) data were used to examine how VA enrollees with mental health-related diagnoses accessed places of care from 1999 to 2009. Population survey weights were applied to the MEPS data, and logit regression was conducted to model how predisposing, enabling, and need factors influence rural veteran health services use (measured by visits to different places of care). Analyses were performed on the subpopulations: rural VA, rural non-VA, urban VA, and urban non-VA enrollees. Findings For all types of care, both rural and urban VA enrollees received care from inpatient, outpatient, office-based, and emergency room settings at higher odds than urban non-VA enrollees. Rural VA enrollees also received all types of care from inpatient, office-based, and emergency room settings at higher odds than urban VA enrollees. Rural VA enrollees had higher odds of a mental health visit of any kind compared to urban VA and non-VA enrollees. Conclusions Based on these variations, the VA may want to develop strategies to increase screening efforts in inpatient settings and emergency rooms to further capture rural VA enrollees who have undiagnosed mental health conditions.