Rural-urban disparities in health outcomes, clinical care, health behaviors, and social determinants of health and an action-oriented, dynamic tool for visualizing them

The relationship between Sense of Community and perceived service quality: rethinking the role of local communities in sustaining rural health and social care

BACKGROUND

Rural areas face unique and interconnected challenges that hinder both access to and quality of health and social services. In response, local communities are increasingly called to proactively engage in identifying their own needs and developing solutions. Sense of Community (SoC) has emerged as a key element in building community capacity and resilience, as well as a crucial protective factor for individual health and well-being. However, the influence of SoC on citizens' perceived service quality remains underexplored. This investigation can provide additional evidence on how SoC reflects the social resources that can be leveraged to address common challenges. To this end, this study examines the relationship between SoC and citizens' perceived quality of health and social services in rural areas.

METHODS

Survey data from 405 citizens who participated in a "Population Experience Observatory" within a community-based participatory research in the rural Serchio Valley of Tuscany, Italy, were used. SoC was measured using an 8-item scale, while perceived quality was assessed through two evaluation ratings-one for health services and one for social services. Ordered logistic regressions were conducted to examine the factors influencing SoC and the relationship between SoC and service evaluations, adjusting for other individual-level and health-related factors.

RESULTS

Higher SoC was significantly associated with more positive evaluations of both health and social services (AOR: 1.49, 95% CI: 1.32-1.69, p < 0.001, and AOR: 1.57, 95% CI: 1.33-1.77, p < 0.001, respectively). Significant factors positively correlated with SoC included older age, better self-reported health, and receiving help from third-sector organizations. Also being a member of these organizations and being raised in the area were positive predictors of SoC but negatively associated with service evaluations.

CONCLUSIONS

This study underscored a significant positive relationship between SoC and perceived service quality. As traditional approaches become less viable due to escalating demands and limited resources, SoC could be a valuable asset for local communities in taking more responsibility for their own health. SoC could be central in shaping a new season of rural health and social care policies aimed at ensuring the sustainable delivery of services. Such policies should emphasize the proactive engagement of local communities and the shift in professional roles from sole providers to advocates and enablers of these empowered communities.

Association Between Healthy Dietary Patterns and Chronic Kidney Disease in Patients with Diabetes: Findings from Korean National Health and Nutrition Examination Survey 2019-2021

Background/Objectives: Although a healthy dietary pattern is a modifiable lifestyle factor in the prevention of chronic kidney disease (CKD), studies that investigate the association between a healthy diet and prevalent CKD in patients with diabetes, using the Korean Healthy Eating Index (KHEI), are lacking. Methods: This cross-sectional study included 1991 patients with diabetes from the eighth Korean National Health and Nutrition Examination Survey 2019-2021. A higher KHEI indicated healthier eating habits. CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 or urine albumin-creatinine ratio ≥ 30 mg/g. The risk of prevalent CKD was evaluated according to the median KHEI value using logistic regression analysis adjusted for various clinicodemographic characteristics. Each KHEI component score was compared between those with and those without CKD, using the Student's t-test. Results: Participants with a higher KHEI were older, with higher proportions of women, non-smokers, and non-alcoholics. A higher KHEI was significantly associated with a lower risk of prevalent CKD (adjusted odds ratio [aOR], 0.73 [0.58-0.93]). Subgroup analysis revealed stronger associations in those without hypertension status (aOR, 0.57 [0.37-0.87]) with at least high school education (aOR, 0.56 [0.38-0.81]). Moreover, patients with diabetes and CKD had significantly lower KHEI, particularly in the adequacy category components, including breakfast consumption, total fruit intake, and dairy product intake. Conclusions: A healthier dietary pattern was associated with a lower risk of prevalent CKD in patients with diabetes. Dietary intervention, which recommends the intake of breakfast, fruits, and dairy products, may be an effective strategy for CKD prevention.

Bidirectional relationships between physical exercise and depressive symptoms among Chinese older adults evidence from the China family panel studies

The study aimed to explore the bidirectional causal relationship between physical activity and depressive symptoms in older adults using a multi-wave follow-up design, expanding on established evidence of a bidirectional relationship between physical activity and depression in older adults. Drawing on individual-level tracking data from the China Family Panel Studies (2016, 2018, and 2020), the causal relationship was tested using fixed effects and cross-lagged panel models. Results indicated that physical exercise was a significant negative predictor of depression in older adults across both continuous (β=-0.056, p < 0.001) and categorical variables (β=-0.536, p < 0.001). After controlling for unobserved confounders, physical exercise continued to have a significant negative impact on depressive symptoms (β=-0.024, p < 0.05; β=- 0.210, p < 0.05). Cross-lagged analyses revealed that physical exercise significantly influenced depressive symptoms only during the T1→T2 phase (β=-0.073, p < 0.001), while depressive symptoms negatively predicted physical activity in later phases (β=-0.068, p < 0.001; β=-0.082, p < 0.001). This finding underscores that while physical exercise can positively impact depressive symptoms in older adults, it may not be sufficient during public health crises or social emergencies. A holistic approach, incorporating social support and psychological interventions, is essential for more effective prevention and management of depressive symptoms.

Examining the Priorities of Local Health Departments in California: A Mixed Methods Study

OBJECTIVE

Prioritization is an essential task of local health departments (LHDs). We examined the alignment of priorities reported in Community Health Needs Assessments (CHNA) with priorities in the Community Health Improvement Plans (CHIP). We report factors that influence the choice of priorities and the alignment of the priorities.

DESIGN

A mixed method study design.

SETTING

California.

PARTICIPANTS

CHNA and CHIP documents were sought for all 58 counties. Interviews were conducted with 19 state and local public health officials.

OUTCOME MEASURES

The priorities in the CHNA and the CHIP were coded as i) only in the CHNA, ii) only in the CHIP, or iii) in both the CHNA and the CHIP. The interviewees were asked to share their experiences related to issue prioritization and decision-making in public health agencies. The interviews were coded and thematically analyzed to identify barriers and facilitators of the prioritization process.

RESULTS

The alignment between the needs prioritized in CHNA and the priorities targeted in CHIP was 35%. The interviews identify reasons for the misalignment, including a need to include priorities in the CHNA even though LHDs are not able to address them, political factors that influence the selection of priorities, and a lack of discretionary funding or capacity/expertise within the agency or its community partners to respond to the needs identified. The lack of discretionary funding was particularly acute for smaller (rural) LHDs (CMSP) and resulted in their often having to focus on priorities where there was state or federal funding.

CONCLUSIONS

LHDs face numerous challenges in aligning the priorities reported in the CHNA and the priorities they focus upon in the CHIP. LHDs should consider using a formal, transparent, and evidence-based approach to setting aligning. Future research should focus on developing a formal decision-making process that is appropriate for local public health decision-making.

How do Chinese people perceive their healthcare system? Inequality in public satisfaction with healthcare security

Background

Satisfaction with healthcare security is a critical indicator of the effectiveness of health systems. Social equity and trust and the financial burden of healthcare are key socioeconomic factors that can significantly influence residents' perceptions of healthcare security. This study aims to investigate the impact of social equity and trust and medical burden on satisfaction with healthcare security and to analyze their potential interaction mechanisms.

Methods

Using data from 7,052 participants in the 2021 China General Social Survey, this study employed machine learning methods, including neural networks (NN), random forests (RF), and logistic regression (LR), to predict and classify satisfaction with healthcare security. Additionally, causal inference techniques were applied to identify the key determinants and estimate their effects on satisfaction levels, thereby uncovering the underlying causal mechanisms.

Results

The predictive performance of the three machine learning methods was similar (p < 0.001). In the original models, the AUCs for LR, NN, and RF were 0.549, 0.563, and 0.534, respectively. After including factors related to social equity and trust, the AUCs for LR, NN, and RF improved to 0.633, 0.638, and 0.611, respectively. Among the three ML models, medical expenses and social equity and trust were identified as the most influential factors. Further causal analysis confirmed that higher levels of social equity and trust increased satisfaction with healthcare security, while a heavier medical burden reduced it. The analysis also revealed significant marginal effects, suggesting that the impact of social equity and trust varied across different levels.

Conclusion

This study highlights the complex relationship between social equity and trust, medical burden, and satisfaction with healthcare security, offering theoretical support for understanding residents' perceptions of healthcare security in various social contexts.

Global, regional, and national burden and trends of intracerebral hemorrhage among adolescents and young adults aged 15-39 years from 1990 to 2021: a comprehensive trend analysis based on the global burden of disease study 2021

Background

Intracerebral hemorrhage (ICH) poses a significant health challenge, notably affecting adolescents and young adults (AYAs) aged 15-39 years. Despite advancements in medical technology, the global burden of ICH remains substantial, influenced by lifestyle factors, socioeconomic conditions, and disparities in healthcare access. This study leverages data from the 2021 Global Burden of Disease (GBD) to conduct a comprehensive analysis of ICH trends and burdens at global, regional, and national levels, emphasizing the role of the Social Development Index (SDI).

Methods

We utilized data from the GBD 2021 to assess the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) associated with ICH from 1990 to 2021, covering 204 countries and regions. Age-standardized rates were calculated to ensure comparability. Temporal trends were evaluated using Joinpoint regression analysis, and future projections were made using a Bayesian Age-Period-Cohort model.

Results

In 2021, ~246,938 new cases of ICH were reported among the global AYAs population, reflecting a decline in age-standardized incidence rates from 11.85 per 100,000 in 1990 to 8.14 in 2021. Prevalence rates also decreased from 124.44 to 94.58 per 100,000. Mortality rates and DALYs exhibited similar downward trends. Significant regional disparities were observed, with high SDI regions experiencing lower ICH burdens than low SDI regions, highlighting the influence of socioeconomic factors and healthcare access.

Conclusion

While the global burden of ICH among AYAs has declined, significant disparities persist, particularly in regions with lower SDI. To further mitigate the impact of ICH, public health initiatives should focus on enhancing healthcare infrastructure, promoting health education, and addressing socioeconomic inequalities.

Drug Overdose Death among Residents of Urban Census Tracts: How Granular Geographical Analyses Uncover Socioenvironmental Correlates in Cuyahoga County, Ohio

Geostatistical data aggregated at state, county, municipality, or ZIP code levels often are utilized for assessing drug overdose epidemic impact and planning resource distribution. Data aggregated at these levels may obscure critical disparities among populations experiencing high rates of drug-related mortality (DRM), especially in densely populated urban areas. Our research was centered on Cuyahoga County (Cleveland), OH, which ranks 15th in the USA for drug-related mortality. This study built on recent efforts that adopted a finer geographical lens by examining DRM rates at the census tract level. Our investigation used Cuyahoga County census tracts with high and low DRM rates and compared them with Cuyahoga County census tracts with high and low levels of opportunity as developed by a publicly available, statewide opportunity index. Analyzing DRM data from 2014 to 2022, we found that the odds of an individual experiencing DRM in low-opportunity areas were quadruple the odds for someone in high-opportunity zones. Our findings highlight the critical need for more granular geographic analysis in urban areas, where heterogenous socioenvironmental conditions appear to correlate with significant heterogeneity in the ways in which residents experience the risk of dying from a drug overdose. By focusing on smaller areas, this approach provides a clearer understanding of the DRM landscape that could facilitate the prioritization of more targeted, culturally centered, public health interventions.

Cardiovascular Health Among Rural and Urban US Adults-Healthcare, Lifestyle, and Social Factors

Importance

Improving cardiovascular health in rural areas is a national priority in the US. However, little is known about the current state of rural cardiovascular health and the underlying drivers of any rural-urban disparities.

Objective

To compare rates of cardiometabolic risk factors and cardiovascular diseases between rural and urban US adults and to evaluate the extent to which health care access, lifestyle factors, and social risk factors contribute to any rural-urban differences.

Design, Setting, and Participants

This nationally representative cross-sectional study analyzed data from US adults aged 20 years or older residing in rural vs urban areas using the 2022 National Health Interview Survey. Data were analyzed between August 2024 and February 2025.

Exposure

County-level rurality.

Main Outcomes and Measures

The primary outcomes were age-standardized rates of cardiometabolic risk factors (hypertension, hyperlipidemia, obesity, and diabetes) and cardiovascular diseases (coronary heart disease [CHD] and stroke).

Results

The study population consisted of 27 172 adults, including 4256 adults (14.0%) residing in rural areas, 14 741 (54.8%) in small or medium metropolitan areas, and 8175 (31.2%) in urban areas. Mean (SD) participant age was 49.1 (17.8) years, and 4399 participants (50.8%) were female. Compared with their urban counterparts, rural adults were more likely to smoke, be insufficiently physically active, and have more social risk factors. Age-standardized rates of cardiometabolic risk factors were significantly higher in rural areas, including hypertension (37.1% vs 30.9%; rate ratio [RR], 1.20; 95% CI, 1.13-1.27), hyperlipidemia (29.3% vs 26.7%; RR, 1.10; 95% CI, 1.03-1.18), obesity (41.1% vs 30.0%; RR, 1.37; 95% CI, 1.27-1.47), and diabetes (11.2% vs 9.8%; RR, 1.15; 95% CI, 1.02-1.29). The same pattern was observed for CHD (6.7% vs 4.3%; RR, 1.58; 95% CI, 1.35-1.85), but no differences were observed for stroke. The magnitude of rural-urban disparities was largest among young adults (aged 20-39 years) for hypertension (RR, 1.44; 95% CI, 1.12-1.86), obesity (RR, 1.54; 95% CI, 1.34-1.77), and diabetes (RR, 2.59; 95% CI, 1.54-4.38). Rural-urban disparities in cardiovascular health were not meaningfully attenuated after adjustment for measures of health care access (insurance coverage, usual source of care, and recent health care utilization) and lifestyle factors (smoking and physical activity). However, accounting for social risk factors (poverty, education level, food insecurity, and home ownership) completely attenuated rural-urban disparities in hypertension (adjusted RR [aRR], 0.99; 95% CI, 0.93-1.06), diabetes (aRR, 1.02; 95% CI, 0.90-1.15), and CHD (aRR, 1.08; 95% CI, 0.91-1.29), but only partially attenuated disparities in obesity (aRR, 1.29; 95% CI, 1.20-1.39).

Conclusions and Relevance

This national cross-sectional study found substantial rural-urban disparities in cardiometabolic risk factors and cardiovascular diseases, which were largest among younger adults and almost entirely explained by social risk factors. These findings suggest that efforts to improve socioeconomic conditions in rural communities may be critical to address the rural-urban gap in cardiovascular health.

Urban-rural differences in pneumonia risk in patients with chronic obstructive pulmonary disease: a nationwide register-based study

Background

Urban-rural differences in treatment within chronic obstructive pulmonary disease (COPD) have been documented in Denmark, and we aim to investigate such differences in the risk of pneumonia.

Methods

A Danish register-based cross-sectional study including patients with an International Classification of Diseases 10th revision (ICD-10) diagnosis code of COPD (J.44) alive on the 31st of December 2018 (99,057 patients). Patients were grouped by municipality type on an urban-rural gradient (capital, metropolitan, provincial, commuter, rural). We identified outpatient pneumonias (redeemed prescriptions of antibiotics typically used for pneumonia) and pneumonia hospitalizations (ICD-10 codes) during 2018. Three groups were defined: 1) No pneumonia, 2) at least one outpatient pneumonia (but no pneumonia hospitalization), and 3) at least one pneumonia hospitalization. A multivariable multinomial logistic regression model was performed with municipality type as main explanatory variable. The 'No pneumonia' group was used as reference outcome group.

Results

Patients outside capital municipalities had significantly increased risk of experiencing outpatient pneumonia (Metropolitan: Odds ratio (OR) = 1.32, 95% confidence interval (CI): 1.25-1.39. Provincial: OR = 1.26, 95% CI: 1.21-1.31. Commuter: OR = 1.25, 95% CI: 1.20-1.31. Rural: OR = 1.28, 95% CI: 1.23-1.33). No significant differences were found for pneumonia hospitalization.

Conclusions

Compared to patients in capital municipalities, patients with a hospital-registered COPD diagnosis in non-capital municipalities had a higher risk of annually redeeming at least one prescription for antibiotics typically used for outpatient pneumonia. We were unable to detect differences in pneumonia hospitalization between municipality types. Our study was not designed to assess causality, and we stress the need for future research to provide actionable insights for health policy makers.

Social needs and health outcomes in two rural Veteran populations

BACKGROUND

Addressing social needs is a priority for many health systems, including the Veterans Health Administration (VA). Nearly a quarter of Veterans reside in rural areas and experience a high social need burden. The purpose of this study was to assess the prevalence and association with health outcomes of social needs in two distinct rural Veteran populations.

METHODS

We conducted a survey (n = 1150) of Veterans at 2 rural VA sites, 1 in the Northeast and 1 in the Southeast (SE), assessing 11 social needs (social disconnection, employment, finance, food, transportation, housing, utilities, internet access, legal needs, activities of daily living [ADL], and discrimination). We ran weighted-logistic regression models to predict the probability of experiencing four outcomes (poor access to care, no-show visits, and self-rated physical and mental health) by individual social need.

FINDINGS

More than 80% of Veterans at both sites reported ≥1 social need, with social disconnection the most common; Veterans at the SE site reported much higher rates. A total of 9 out of 11 needs were associated with higher probability of poor physical and mental health, particularly financial needs (average marginal effect [AME]: 0.21-0.32, p < 0.001) and ADL (AME: 0.27-0.34, p < 0.001). We found smaller associations between social needs and poor access to care and no-show visits.

CONCLUSION

High prevalence of social needs in rural Veteran population and significant associations with four health outcomes support the prioritization of addressing social determinants of health for health systems. Differences in the findings between sites support tailoring interventions to specific patient populations.

'In our culture, we come when you die': Qualitative descriptive analysis of end-of-life perspectives in a reservation-based community

AIM

To explore (1) perspectives and attitudes of Native Americans regarding transitions from serious illness to death, and (2) awareness about hospice and palliative care service models in a Great Plains reservation-based community.

DESIGN

Qualitative descriptive study.

METHODS

Community members and clinicians were invited to participate in a semi-structured focus group or interview by Tribal Advisory Board members. Analysis involved three phases: (1) qualitative descriptive analysis of preliminary themes using the Addressing Palliative Care Disparities conceptual model; (2) a cultural review of the data; and (3) reflexive thematic analysis to synthesize findings.

RESULTS

Twenty-six participants engaged in two focus groups (n = 5-6 participants in each) and interviews (n = 15). Four themes were derived from their stories: (1) family connectedness is always priority; (2) end-of-life support is a community-wide effort; (3) everyone must grieve in their own way to heal; and (4) support needs from outside the community.

CONCLUSION

Findings highlight cultural considerations spanning the life course. Clinicians, researchers and traditional wisdom keepers and practitioners, particularly those working in rural and/or reservation-based settings, must provide culturally safe care. This must include acknowledging and prioritizing the needs and preferences of Native American patients and the impact on their families and communities.

IMPACT AND IMPLICATIONS FOR THE PROFESSION

Leveraging community assets, such as family and social networks, is key for supporting Native American patients with serious illnesses. Additionally, facilitating greater family and caregiver involvement along a patient's care trajectory may be a pathway for easing health care workers' caseloads in reservation-based areas, where resources are limited.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline was used.

PATIENT/PUBLIC CONTRIBUTION

The study was ideated based on community insight. Tribal Advisory Board members oversaw all aspects including recruitment, data acquisition, interpretation of findings and tribal data dissemination.

Challenges and Supports for Implementing Health Equity During National Accreditation Among Small Local Health Departments in the United States

OBJECTIVE

This article focuses on supports and challenges to health equity that small local health departments (LHDs) experienced while working toward national reaccreditation or Pathways Recognition with the Public Health Accreditation Board's Standards & Measures Version 2022 (PHAB S&M v2022).

DESIGN

The study team conducted 22 qualitative interview sessions with members of health department leadership teams.

SETTING

In the spring of 2024, participants from 4 small LHDs in the western and midwestern regions of the United States participated in individual remote interview sessions.

PARTICIPANTS

Participants were members of leadership teams in LHDs with population jurisdictions less than 50 000.

MAIN OUTCOME MEASURES

Common challenges relating to the health equity measures in the PHAB S&M v2022 included external influences on equity language; lack of small population data; and racially and ethnically homogeneous populations and staff. The main support was the national equity standards provided justification for pursuing equity work.

RESULTS

Strategies to overcome challenges associated with the equity measures included staff training, seeking alternative equity language, and examining socioeconomic inequities in addition to race and ethnicity. Internal workforce understanding of health equity was improved through department-wide training initiatives. When working under restrictive language requirements for state agencies, grants, and other funding sources, staff suggested using alternative phrases and keywords such as level playing field and equal access . When addressing racially and ethnically homogenous populations, staff pursued equity in terms of income and focused on those living with pre-existing conditions (ie, diabetes).

CONCLUSIONS

Ensuring that LHDs can work toward health equity is crucial for reducing health inequities. While the equity focus of PHAB S&M v2022 proved challenging, for this selection of LHDs, participants affirmed that PHAB accreditation allowed them to solidify their equity work to better serve their communities.

Healthy lifestyle behaviors and depressive symptoms: a national cross-sectional study of the older adults in China

INTRODUCTION

This investigation assesses the impact of healthy lifestyle behaviors on depressive symptoms among older adults in China, utilizing data from the 2020 China Health and Retirement Longitudinal Study (CHARLS).

METHODS

The analysis included 9,020 valid samples from individuals aged 60 and above. Sleep duration, social participation, and physical exercise were examined as independent variables. Depressive symptoms were measured using the CESD-10 scale, with relationships analyzed through an ordered logistic regression model.

RESULTS

The study reveals significant correlations between healthy lifestyle behaviors - specifically adequate sleep, regular physical exercise, and active social participation - and reduced prevalence of depressive symptoms in the elderly (p < 0.05).

DISCUSSION

These findings underscore the potential of healthy lifestyle interventions as key strategies in alleviating the mental health burden among China's aging population. Integration of these results into public health policies is recommended to enhance the mental well-being of older adults.

Urban and rural residence: their influence on food group consumption in Iran

BACKGROUND

Urbanization is expanding in Iran, leading to the emergence of three distinct socio-geographical areas: urban, rural, and suburban areas. These different areas may exhibit significant variations in dietary patterns. This study investigates the association between people's place of residence and their consumption of different food groups.

METHODS

This study utilized data from Iran's Food and Nutrition Surveillance System (FNS). A total of 1697 participants were randomly recruited from different rural (N = 568), urban (N = 568), and suburban (N = 561) regions across Iran. Their food intake was assessed using a validated dish-based semi-quantitative food frequency questionnaire (DB-FFQ).

RESULTS

Rural males consumed significantly more grains (35.51 g/day, p = 0.03) than urban males, while rural females consumed significantly less dairy (-30.07 g/day, p = 0.03) than urban females. Additionally, rural males and females consumed significantly more fats and oils (3.72 g/day, p = 0.01 for males and 5.2 g/day, p < 0.001 for females) than their urban counterparts. Moreover, both suburban females and males were found to consume significantly less fruit compared to urban individuals, with suburban females consuming - 47.41 g/day (p < 0.001) less fruit and suburban males consuming - 60.42 g/day (p = 0.001) less fruit.

CONCLUSION

Findings showed that rural men's diets are characterized by higher consumption of grains and fats, while urbanization is linked to increased dairy consumption in women. Additionally, the study highlights a worrying lack of fruit consumption in suburban areas. These findings underscore the necessity of implementing specific nutritional policies to promote dietary diversity in various residential areas.

Health differences between rural and non-rural Texas counties based on 2023 County Health Rankings

BACKGROUND

Place matters for health. In Texas, growing rural populations face a variety of structural, social, and economic disparities that position them for potentially worse health outcomes. The current study contributes to understanding rural health disparities in a state-specific context.

METHODS

Using 2023 County Health Rankings data from the University of Wisconsin Population Health Institute, the study analyzes rural/non-rural county differences in Texas across six composite indexed domains of health outcomes (length of life, quality of life) and health factors (health behavior, clinical care, socioeconomic factors, physical environment) with a chi-square test of significance and logistic regression.

RESULTS

Quartile ranking distributions of the six domains differed between rural and non-rural counties. Rural Texas counties were significantly more likely to fall into the bottom quartile(s) in the domains of length of life and clinical care and less likely to fall into the bottom quartile(s) in the domains of quality of life and physical environment. No differences were found in the domains of health behavior and socioeconomic factors. Findings regarding disparities in length of life and clinical care align with other studies examining disease prevalence and the unavailability of many health services in rural Texas. The lack of significant differences in other domains may relate to indicators that are not present in the dataset, given studies that find disparities relating to other underlying factors.

CONCLUSIONS

Texas County Health Rankings data show differences in health outcomes and factors between rural and non-rural counties. Limitations of findings relate to the study's cross-sectional design and parameters of the secondary data source. Ultimately, results can help state health stakeholders, especially those in community or operational contexts with limited resources or access to more detailed health statistics, to use the CHR dataset to consider more relevant local interventions to address rural health disparities.

"Everything cannot be handled virtually": Understanding intention and use of digital health technologies among rural adults and rural cancer survivors

PURPOSE

This qualitative study assessed internet access and use, barriers and facilitators to participating in digital health interventions or programs, and the engagement experience in virtual versus in-person health interventions among rural adults and rural cancer survivors.

METHODS

Rural adults (n = 10) and rural cancer survivors (n = 10) were recruited from previous studies to participate in an in-depth interview. The interview guide contained eight open-ended questions related to participation in technology-based programs. Interviews were recorded and transcribed, and transcripts were analyzed for emergent themes using a thematic content analysis approach.

FINDINGS

Rural adults were younger (M age = 37.9 ± 11.8 years), more likely to be non-Hispanic Black (90.0%), and reported higher educational attainment (50.0% earned a master's or doctoral degree) compared with rural cancer survivors (M age = 63.0 ± 9.1 years, 70.0% non-Hispanic White, and 20.0% earned a master's or doctoral degree). Participants discussed performance and effort expectancies related to using digital health technologies or participating in virtual programs and cited positive and negative aspects of in-person and virtual platforms. Participants emphasized the need for social connections and missed opportunities in current virtual offerings along with factors that influence their use of technologies (e.g., prior experience, tech anxiety).

CONCLUSIONS

Findings from this qualitative study provide an in-depth understanding of the intricate experiences of rural adults and rural cancer survivors when engaging with digital health technologies. Integrating the experiences of rural adults and rural cancer survivors may aid in developing clinical and community-based interventions and policies that support increasing access to digital health services and programs for rural communities.

Learning by Doing, and Doing it Right - Building a Multi-Dimensional Social Determinants of Health Curriculum in a Rural Internal Medicine Residency

OBJECTIVES

While there has been increasing awareness of the importance of social determinants of health (SDOH) learning for internal medicine residents and physicians, only a few residency programs have incorporated training into their curricula. For those who did, the curricula were often didactic and lacked action-driven components or community partnership. Therefore, we built an experiential SDOH curriculum with an action-driven element and emphasis on community partnerships in a newly established residency program in rural New York.

METHODS

Over 24 months, 22 internal medicine residents were engaged in SDOH lectures, workshops, and action-driven learning through implementing screening tools in residency clinics and working with community partners. After the curriculum, residents' competency in addressing SDOH needs was assessed through Likert-scale questionnaires. Focused interviews were conducted among participating residents and faculty to obtain qualitative feedback on the curriculum.

RESULTS

Participating resident physicians demonstrated competency in recognizing and addressing SDOH needs after curriculum completion (mean competency score = 4.04). A significant increase in residents' self-rated confidence in addressing SDOH was observed after training (P = .002). Residents reported enhanced relationships with patients, effective utilization of community resources, and readiness to apply SDOH knowledge and skills to their future practice. Residents and faculty also discussed the SDOH challenges unique to rural primary care through their experiences.

CONCLUSION

This curriculum provides insights into an educational framework that improves residents' SDOH awareness, integrates SDOH into resident physicians' daily practice, and facilitates community collaboration. While challenges unique to rural primary care exist, this curriculum demonstrated the feasibility of longitudinal, action-driven, and community-centered SDOH education in rural areas that may inform future programs' curricular design.

Using the social cognitive theory to examine spontaneous attempts to quit illicit substance use

Rural areas in the US exhibit high rates of illicit substance use. This study aimed to investigate the Social Cognitive Theory factors associated with spontaneous attempts to quit illicit substance use in a sample of users. A cross-sectional survey was administered through face-to-face interviews. Data was collected from adult (≥ 18 years of age) current illicit substance users who were not receiving professional addiction treatment. Binary logistic regression analyses were utilized to answer the research question. Data from 230 illicit substance users met the eligibility criteria. The mean age was 38 years, whereas the average history of illicit substance use was 14 years. Users with a higher perceived value of quitting illicit substance use were significantly more likely to attempt to quit use spontaneously. Health behavior interventions that incorporate the perceived value of quitting illicit substance use can be effective in encouraging spontaneous attempts to quit illicit substance use.

County-Level Enrollment in Medicare Advantage Plans Offering Expanded Supplemental Benefits

Importance

Since 2019 and 2020, Medicare Advantage (MA) plans have been able to offer supplemental benefits that address long-term services and supports (LTSS) and social determinants of health (SDOH).

Objective

To examine the temporal trends and geographic variation in enrollment in MA plans offering LTSS and SDOH benefits.

Design, Setting, and Participants

This cross-sectional study used publicly available data to examine changes in beneficiary enrollment and plan offerings of LTSS and SDOH benefits from the benefits data from the second quarter of each year and other data from April of each year except 2024, for which the first quarter was the latest for benefits data and January the latest for other data at the time of analysis. Multivariable linear regression models for each type of benefit were used to investigate associations between county characteristics and enrollment in 2024. Analyses were stratified for (1) Dual Eligible Special Needs Plans (D-SNPs) that exclusively enroll dual-eligible beneficiaries and (2) non-D-SNPs.

Main Outcomes and Measures

The percentage of MA enrollees in plans offering LTSS or SDOH benefits at the county level.

Results

This study included 2 631 697 D-SNP and 20 114 506 non-D-SNP enrollees in 2020, which increased to 5 494 426 and 25 561 455, respectively, in 2024. From 2020 to 2024, the percentage of D-SNP enrollees in plans offering SDOH benefits increased from 9% to 46%, whereas the percentage fluctuated between 23% and 39% for LTSS benefits. There was an increase in non-D-SNP enrollees with LTSS (from 9% to 22%) and SDOH (from 4% to 20%) benefits from 2020 to 2023, which decreased in 2024. In 2024, the most offered LTSS benefit was in-home support services, and the most offered SDOH benefit was food and produce. The percentage of enrollees with these benefits varied across counties in 2024. In multivariable linear regression models, among D-SNPs, enrollment in plans offering any SDOH benefits was higher in counties with greater MA penetration (coefficient, 5.0 percentage points [pp] per 10-pp change; 95% CI, 2.1-7.9 pp), in urban counties (coefficient, 7.2 pp vs rural counties; 95% CI, 3.8-10.6 pp), in counties with greater enrollment in fully integrated D-SNPs (coefficient, 3.0 pp per 10-pp change; 95% CI, 2.2-3.9 pp), and in counties in states with approved Medicaid home- and community-based services waivers for individuals 65 years or older or those with disabilities (coefficient, 10.8 pp; 95% CI, 4.0-17.6 pp). Enrollment in D-SNPs offering LTSS benefits was also higher in counties with greater MA penetration (coefficient, 5.9 pp per 10-pp change; 95% CI, 2.4-9.5 pp), urban vs rural counties (coefficient, 4.6 pp; 95% CI, 1.1-8.1 pp), and counties with greater enrollment in fully integrated D-SNPs (coefficient, 3.0 pp per 10-pp change; 95% CI, 2.1-3.9 pp) in addition to counties with greater social vulnerability scores (coefficient, 1.4 pp per 10-pp change; 95% CI, 0.3-2.5 pp).

Conclusions and Relevance

In this cross-sectional study of MA plans and enrollees, an increase in enrollment was most consistent in D-SNPs offering SDOH benefits compared with LTSS benefits and in D-SNPs compared with non-D-SNPs. Geographic variation in enrollment patterns highlights potential gaps in access to LTSS and SDOH benefits for rural MA beneficiaries and dual-eligible enrollees living in counties with lower enrollment in fully integrated D-SNPs and states with more limited Medicaid home- and community-based services coverage.

Fungal Infections and Social Determinants of Health: Using Data to Identify Disparities

Purpose of Review

Fungal diseases disproportionately affect certain demographic populations, but few studies have thoroughly investigated the drivers of those disparities. We summarize data sources that can be considered to explore potential associations between fungal diseases and social determinants of health in the United States.

Recent Findings

Sociodemographic disparities are apparent in fungal diseases, and social determinants of health (e.g., income, living conditions, and healthcare access) may be associated with increased risk of infection, severe disease, and poor health outcomes.

Summary

Numerous data sources are available in the United States to analyze the potential association between fungal diseases and underlying social determinants of health. Each source has benefits and limitations that should be considered in the development of analysis plans. Inherent challenges to all fungal disease data (e.g., underdiagnosis, underreporting, and inability to detect people who do not seek medical care) should be noted and accounted for in interpretation of results.