Person and place: the compounding effects of race/ethnicity and rurality on health

Substance use disorders among African-American men in the rural south: A scoping review

African American (AA) men in the rural South may be at high risk for experiencing adverse health outcomes from substance use (SU). We conducted a scoping review to explore the research on SU among rural AA men in the rural South of the United States (US). Ten articles addressed the following thematic areas pertaining to SU: factors associated with SU (n = 6), associations between substance use and health outcomes (n = 2), and the influence of impulsivity on SU (n = 2). Additional research on SU among AA men in the rural South is needed, particularly pertaining to treatment-related considerations.

Impacts of Diabetes Stigma on Acute Health Care Utilization Among Adults With Type 2 Diabetes

PurposeThe purpose of this study was to examine the relationships between diabetes stigma, patient activation, and acute health care use. It was predicted that greater diabetes stigma would be associated with lower patient activation and greater likelihood of acute health care utilization.MethodsPrimary data were collected cross-sectionally using a web-based panel of US adults with type 2 diabetes (N = 371). Participants were screened for eligibility by providing informed consent, reporting a type 2 diabetes diagnosis from a health care provider, and passing an end-of-survey check to corroborate participants' initial self-reported diagnosis of type 2 diabetes. The Diabetes Stigma Assessment Scale, with its 3 subscales, assessed blame and judgment, perceived discrimination, and self-stigma associated with having diabetes. Patient activation was measured using the Patient Activation Measure. The frequency of diabetes-related emergency department visits and hospitalizations during the prior 12 months measured acute health care use.ResultsSelf-stigma was significantly associated with lower levels of patient activation, and blame and judgment and perceived discrimination were not. Perceived discrimination was also significantly associated with greater risk of emergency department visits and hospitalizations, and self-stigma and blame and judgment were not associated with either indicator of acute health care use.ConclusionsResults suggest self-stigma is associated with lower levels of patient activation and that perceived discrimination is related to increased use of acute health care. Future research may examine avenues to reduce diabetes stigma and its effect on patient activation and acute health care utilization.

Longer travel times to acute hospitals are associated with lower likelihood of cancer screening receipt among rural-dwelling adults in the U.S. South

PURPOSE

Given rural hospitals' role in providing outpatient services, we examined the association between travel burdens and receipt of cancer screening among rural-dwelling adults in the U.S. South region.

METHODS

First, we estimated network travel times and distances to access the nearest and second nearest acute care hospital from each rural census tract in the U.S. South. After appending the Centers for Disease Control's PLACES dataset, we fitted generalized linear mixed models.

RESULTS

Longer distances to the second nearest hospital are negatively associated with breast, colorectal, and cervical cancer screening receipt among eligible rural-dwelling adults. Rural-dwelling women in counties with 1 closure had reduced likelihood of breast cancer screening. Residence in a partial- or whole-county Health Professional Shortage Area (HPSA) was negatively associated with cancer screening receipt. Specialist (OB/GYN and gastroenterologist) supply was positively associated with receipt of cancer screening. Uninsurance was positively associated with cervical and breast cancer screening receipt. Medicaid expansion was associated with increased breast and cervical cancer screening.

CONCLUSIONS

Rural residents in partial-county primary care HPSAs had the lowest rates of breast, cervical, and colorectal cancer screening, compared with whole-county HPSAs and non-shortage areas. These residents also faced the greatest distances to their nearest and second nearest hospital. This is notable because rural residents in the South face greater travel burdens for cancer care compared with residents in other regions. Finally, the positive association between uninsurance and breast and cervical cancer screening may reflect the CDC's National Breast and Cervical Cancer Early Detection Program's effectiveness.

Health care access barriers among metropolitan and nonmetropolitan populations of eight geographically diverse states, 2018

INTRODUCTION

Nonmetropolitan populations face frequent health care access barriers compared to their metropolitan counterparts, but differences in the number of these barriers across groups are not known. Our objective was to examine the differences in health care access barriers across metropolitan, micropolitan, and noncore populations.

METHODS

We used Behavioral Risk Factor Surveillance System data from the optional "Health Care Access" module to perform a cross-sectional analysis examining access barriers across levels of rurality using bivariate analyses and Poisson models. Access barriers were operationalized as a count ranging from 0 to 5, reflective of the number of financial barriers and nonfinancial barriers.

RESULTS

Micropolitan and noncore respondents had lower educational attainment, were older, and were less racially/ethnically diverse than metropolitan respondents. They also reported more barriers, including lacking health insurance, medical debt, and foregoing care or medication due to cost. These barriers were most pronounced in non-Hispanic Black, Hispanic, and American Indian/Alaska Native nonmetropolitan populations, compared to their White counterparts. In adjusted analysis, micropolitan respondents reported more barriers compared to metropolitan (prevalence rate ratio = 1.06; 95% confidence interval: 1.02-1.10) as did women, racial/ethnic minority populations, and those with less education.

CONCLUSIONS

Micropolitan populations experience more barriers to health care, and nonmetropolitan respondents report more cost-related barriers than their metropolitan counterparts, raising concerns on health care disparities and financial burdens for these underserved populations. This underscores the need to mitigate these barriers, particularly among those in micropolitan areas and minorized populations.

Rural-Urban Health Care Cost Differences Among Latinx Adults With and Without Dementia in the United States

OBJECTIVES

To compare rural-urban health care costs among Latinx adults ages 51+ and examine variations by dementia status.

METHODS

Data are from the Health and Retirement Study (2006-2018 waves; n = 15,567). We inflation-adjusted all health care costs using the 2021 consumer price index. Geographic context and dementia status were the main exposure variables. We applied multivariate two-part generalized linear models and adjusted for sociodemographic and health characteristics.

RESULTS

Rural residents had higher total health care costs, regardless of dementia status. Total health care costs were $850 higher in rural ($2,640) compared to urban ($1,789) areas (p < .001). Out-of-pocket costs were $870 higher in rural ($2,677) compared to urban ($1,806) areas (p < .001). Dementia status was not an effect modifier.

DISCUSSION

Health care costs are disproportionately higher among Latinx rural, relative to urban, residents. Addressing health care costs among Latinx rural residents is a public health priority.

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Rural and Ethnic Disparities in Out-of-hospital Care and Transport Pathways After Road Traffic Trauma in New Zealand

Introduction

The out-of-hospital emergency medical service (EMS) care responses and the transport pathways to hospital play a vital role in patient survival following injury and are the first component of a well-functioning, optimised system of trauma care. Despite longstanding challenges in delivering equitable healthcare services in the health system of Aotearoa-New Zealand (NZ), little is known about inequities in EMS-delivered care and transport pathways to hospital-level care.

Methods

This population-level cohort study on out-of-hospital care, based on national EMS data, included trauma patients <85 years in age who were injured in a road traffic crash (RTC). In this study we examined the combined relationship between ethnicity and geographical location of injury in EMS out-of-hospital care and transport pathways following RTCs in Aotearoa-NZ. Analyses were stratified by geographical location of injury (rural and urban) and combined ethnicity-geographical location (rural Māori, rural non-Māori, urban Māori, and urban non-Māori).

Results

In a two-year period, there were 746 eligible patients; of these, 692 were transported to hospital. Indigenous Māori comprised 28% (196) of vehicle occupants attended by EMS, while 47% (324) of patients' injuries occurred in a rural location. The EMS transport pathways to hospital for rural patients were slower to reach first hospital (total in slowest tertile of time 44% vs 7%, P ≥ 0.001) and longer to reach definitive care (direct transport, 77% vs 87%, P = 0.001) compared to urban patients. Māori patients injured in a rural location were comparatively less likely than rural non-Māori to be triaged to priority transport pathways (fastest dispatch triage, 92% vs 97%, respectively, P = 0.05); slower to reach first hospital (total in slowest tertile of time, 55% vs 41%, P = 0.02); and had less access to specialist trauma care (reached tertiary trauma hospital, 51% vs 73%, P = 0.02).

Conclusion

Among RTC patients attended and transported by EMS in NZ, there was variability in out-of-hospital EMS transport pathways through to specialist trauma care, strongly patterned by location of incident and ethnicity. These findings, mirroring other health disparities for Māori, provide an equity-focused evidence base to guide clinical and policy decision makers to optimize the delivery of EMS care and reduce disparities associated with out-of-hospital EMS care.

Regional and racial disparities in major amputation rates among medicare beneficiaries with diabetes: a retrospective study in the southeastern USA

Objective

While rates for non-traumatic lower extremity amputations (LEA) have been declining, concerns exist over disparities. Our objectives are to track major LEA (MLEA) rates over time among Medicare beneficiaries residing in a high diabetes prevalence region in the southeastern USA (the diabetes belt) and surrounding areas.

Methods

We used Medicare claims files for ~900 000 fee-for-service beneficiaries aged ≥65 years in 2006-2015 to track MLEA rates per 1000 patients with diabetes. We additionally conducted a cross-sectional analysis of data for 2015 to compare regional and racial disparities in major amputation risks after adjusting for demographic, socioeconomic, access-to-care and foot complications and other health factors. The Centers for Disease Control and Prevention defined the diabetes belt as 644 counties across Appalachian and southeastern US counties with high prevalence.

Results

MLEA rates were 3.9 per 1000 in the Belt compared with 2.8 in the surrounding counties in 2006 and decreased to 2.3 and 1.6 in 2015. Non-Hispanic black patients had 8.5 and 6.9 MLEAs per 1000 in 2006 and 4.8 and 3.5 in 2015 in the Belt and surrounding counties, respectively, while the rates were similar for non-Hispanic white patients in the two areas. Although amputation rates declined rapidly in both areas, non-Hispanic black patients in the Belt consistently had >3 times higher rates than non-Hispanic whites in the Belt. After adjusting for patient demographics, foot complications and healthcare access, non-Hispanic blacks in the Belt had about twice higher odds of MLEAs compared with non-Hispanic whites in the surrounding areas.

Discussion

Our data show persistent disparities in major amputation rates between the diabetes belt and surrounding counties. Racial disparities were much larger in the Belt. Targeted policies to prevent MLEAs among non-Hispanic black patients are needed to reduce persistent disparities in the Belt.

See Me, Hear Me, Know Me: Perspectives on Diet and Physical Activity Influences among Teens Living in Rural Texas Communities

Teens in rural communities are at greater risk of obesity than teens in urban areas. Diet and physical activity influence obesity risk. Understanding their perspectives is an important step in intervention design. This qualitative investigation explored teen perspectives on how living in a rural community influenced their diet and physical activity choices. Forty parent-teen pairs were recruited. Data collection included surveys and telephone interviews. This paper reports teen perspectives identified in the first interview. Thematic analysis was used to code and analyze the data. Findings revealed that the primary factor driving teens' diet and physical activity behaviors was the teens themselves. They clearly understood their role in the choices they made, although they acknowledged not always making the healthiest choice. This belief was driven by their motivation to engage in healthy behaviors, which was influenced by the perceived benefits derived from making healthy choices and from the synergistic relationship between diet and physical activity. Diet and physical activity, in turn, were influenced by the environment, particularly the home, social, and community environments. Family and friends were particularly influential, as well as resource availability. These findings can serve as a foundation for designing interventions tailored to this population.

Depression among Korean American immigrants living in rural Alabama: use of social determinants of health framework

OBJECTIVES

Depression among Korean American (KA) immigrants in rural Alabama is understudied. This study aims to utilize the social determinants of health (SDOH) framework to explore factors associated with depressive symptoms among KA immigrants living in rural communities of Alabama.

DESIGN

Data were collected from two sites in rural Alabama from September 2019 to February 2020. Convenience sampling was conducted to recruit study participants from the KA community. A total number of 261 KA immigrants aged 23-75 were included in the study. All measures originally in English were translated into Korean using back-translation to assure comparability and equivalence in the meaning of measures. Multiple linear regression modeling was used to explore the predictors of depression.

RESULTS

Perceived race discrimination was significantly associated with greater depressive symptoms (β = .180, SE = .534, p < .01). Three SDOH were identified to have significant relationship with depressive symptoms. Participants who could not see a doctor because of cost (β = .247, SE = 1.118, p < .001), had lower level of health literacy (β = -.121, SE = .280, p < .05), and had higher social isolation scores (β = .157, SE = .226, p < .05) tended to have higher scores of depressive symptoms.

CONCLUSION

Rural-living KA immigrants' depression can be significantly affected by race discrimination and SDOH factors, emphasizing the need for culturally competent interventions and services. Policymakers, federal and local governments, non-governmental organizations, and social workers can make joint efforts to address racial discrimination and improve the mental health services among immigrant populations, especially those living in rural areas.

Urban-rural health disparities in Brazil: Do sociodemographic attributes play a role?

The debate over urban-rural health disparities in Latin American countries is disputed, and this relationship may not be as straightforward as initially thought. In this study, we investigate whether individual-level self-rated health (SRH) varies across urban and rural populations in the country and how sociodemographic attributes are associated with such differences. We relied on data from the Brazilian National Health Survey (n = 78,806), a nationwide household-based survey conducted in 2019 that is representative of Brazil, geopolitical macro-regions, states, and 27 state capitals. Logistic regression models were used to test for differences in SRH between urban and rural inhabitants. The findings suggest that Brazilian adults living in rural areas are at a higher risk of perceiving their health as poor than their urban counterparts. The urban-rural health disparities are significant and influenced by sociodemographic attributes, highlighting the importance of developing public health interventions to improve health outcomes in these populations.

Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018

Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long-term policy solutions including reparations are needed to address these underlying processes.

CONTEXT

The growing rate of rural hospital closures elicits concerns about declining access to hospital-based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure-Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care.

METHODS

To calculate spatial access, we estimated the network travel distance and time between the census tract-level population-weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital-based care in 2018, we estimated three-level (tract, county, state-level) generalized linear models.

FINDINGS

We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital.

CONCLUSIONS

Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.

The association between social functioning and health literacy among rural Southeastern African Americans with hypertension

African Americans living in low socioeconomic circumstances are at high risk of poor health outcomes; this is particularly true for those with hypertension. Many African Americans with chronic hypertension living in the rural impoverished Southeastern USA have low health literacy and are socially isolated. These factors are known to have a negative impact on health outcomes, but it is possible that social support may overcome some of the effect of low health literacy. Since little has been reported about this association, we examined the association between social functioning and health literacy in a rural African American population in the Southeast USA. We used baseline data from participants in the Southeastern Collaboration to Improve Blood Pressure Control, a pragmatic trial that recruited rural African Americans with persistently uncontrolled hypertension and collected survey data. Overall, 33.5% of the 1221 person sample reported social isolation, 26.0% reported low instrumental support, 36.0% reported low emotional support, and 63.4% had inadequate health literacy. All three domains of low social functioning were significantly associated with low health literacy, and this effect was robust to multivariable adjustment for sociodemographics and cognitive functioning for social isolation (adjusted odds ratio 1.62, 95% confidence intervals 1.20-2.20). In conclusion, the majority of this sample living in the NC and AL Black Belt had high social functioning but inadequate health literacy. Tests of interventions to improve social support, especially social isolation, may be warranted to overcome low health literacy in this high-risk rural population.

American Indians travel great distances for obstetrical care: Examining rural and racial disparities

Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014-2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14-44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

INTRODUCTION

Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion.

RESEARCH DESIGN AND METHODS

This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black.

RESULTS

Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black.

CONCLUSIONS

A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.

Engagement and Utilization of a Complete Remote Digital Care Program for Musculoskeletal Pain Management in Urban and Rural Areas Across the United States: Longitudinal Cohort Study

BACKGROUND

Musculoskeletal (MSK) conditions are the number one cause of disability worldwide. Digital care programs (DCPs) for MSK pain management have arisen as alternative care delivery models to circumvent challenges in accessibility of conventional therapy. Despite the potential of DCPs to reduce inequities in accessing care, the outcomes of such interventions in rural and urban populations have yet to be studied.

OBJECTIVE

The aim of this study was to assess the impact of urban or rural residency on engagement and clinical outcomes after a multimodal DCP for MSK pain.

METHODS

This study consists of an ad hoc analysis of a decentralized single-arm investigation into engagement and clinical-related outcomes after a multimodal DCP in patients with MSK conditions. Patients were coded according to their zip codes to a specific rural-urban commuting area code and grouped into rural and urban cohorts. Changes in their engagement and clinical outcomes from baseline to program end were assessed. Latent growth curve analysis was performed to estimate change trajectories adjusting for the following covariates: age, gender, BMI, employment status, and pain acuity. Outcomes included engagement, self-reported pain, and the results of the Generalized Anxiety Disorder 7-item, Patient Health Questionnaire 9-item, and Work Productivity and Activity Impairment scales. A minimum clinically important difference (MCID) of 30% was considered for pain.

RESULTS

Patients with urban and rural residency across the United States participated in the program (n=9992). A 73.8% (7378/9992) completion rate was observed. Both groups reported high satisfaction scores and similar engagement with exercise sessions, with rural residents showing higher engagement with educational content (P<.001) and higher program completion rates (P=.02). All groups showed a significant improvement in all clinical outcomes, including pain, mental health, and work productivity, without statistically significant intergroup differences. The percentage of patients meeting the MCID was similar in both groups (urban: 67.1%, rural: 68.3%; P=.30).

CONCLUSIONS

This study advocates for the utility of a DCP in improving access to MSK care in urban and rural areas alike, showcasing its potential to promote health equity. High engagement, satisfaction, and completion rates were noted in both groups, as well as significant improvements in clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

Assessing community-level exposure to social vulnerability and isolation: spatial patterning and urban-rural differences

BACKGROUND

Environmental health disparity research involves the use of metrics to assess exposure to community-level vulnerabilities or inequities. While numerous vulnerability indices have been developed, there is no agreement on standardization or appropriate use, they have largely been applied in urban areas, and their interpretation and utility likely vary across different geographies.

OBJECTIVE

We evaluated the spatial distribution, variability, and relationships among different metrics of social vulnerability and isolation across urban and rural settings to inform interpretation and selection of metrics for environmental disparity research.

METHODS

For all census tracts in North Carolina, we conducted a principal components analysis using 23 socioeconomic/demographic variables from the 2010 United States Census and American Community Survey. We calculated or obtained the neighborhood deprivation index (NDI), residential racial isolation index (RI), educational isolation index (EI), Gini coefficient, and social vulnerability index (SVI). Statistical analyses included Moran's I for spatial clustering, t-tests for urban-rural differences, Pearson correlation coefficients, and changes in ranking of tracts across metrics.

RESULTS

Social vulnerability metrics exhibited clear spatial patterning (Moran's I ≥ 0.30, p < 0.01). Greater educational isolation and more intense neighborhood deprivation was observed in rural areas and greater racial isolation in urban areas. Single-domain metrics were not highly correlated with each other (rho ≤ 0.36), while composite metrics (i.e., NDI, SVI, principal components analysis) were highly correlated (rho > 0.80). Composite metrics were more highly correlated with the racial isolation metric in urban (rho: 0.54-0.64) versus rural tracts (rho: 0.36-0.48). Census tract rankings changed considerably based on which metric was being applied.

SIGNIFICANCE

High correlations between composite metrics within urban and rural tracts suggests they could be used interchangeably; single domain metrics cannot. Composite metrics capture different facets of vulnerabilities in urban and rural settings, and these complexities should be examined by researchers applying metrics to areas of diverse urban and rural forms.

Environmental justice and allergic disease: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee and the Diversity, Equity and Inclusion Committee

Environmental justice is the concept that all people have the right to live in a healthy environment, to be protected against environmental hazards, and to participate in decisions affecting their communities. Communities of color and low-income populations live, work, and play in environments with disproportionate exposure to hazards associated with allergic disease. This unequal distribution of hazards has contributed to health disparities and is largely the result of systemic racism that promotes segregation of neighborhoods, disinvestment in predominantly racial/ethnic minority neighborhoods, and discriminatory housing, employment, and lending practices. The AAAAI Environmental Exposure and Respiratory Health Committee and Diversity, Equity and Inclusion Committee jointly developed this report to improve allergy/immunology specialists' awareness of environmental injustice, its roots in systemic racism, and its impact on health disparities in allergic disease. We present evidence supporting the relationship between exposure to environmental hazards, particularly at the neighborhood level, and the disproportionately high incidence and poor outcomes from allergic diseases in marginalized populations. Achieving environmental justice requires investment in at-risk communities to increase access to safe housing, clean air and water, employment opportunities, education, nutrition, and health care. Through policies that promote environmental justice, we can achieve greater health equity in allergic disease.

Depression among people with chronic skin disease at Boru Meda Hospital in Northeast Ethiopia

BACKGROUND

The comorbidity of depression with chronic skin disease negatively affects the quality of life and disease prognosis, creating an immense burden on patients, families, and the wider community. However, there are limited studies conducted on the prevalence of depression and associated factors among people with chronic skin disease in Ethiopia.

OBJECTIVE

This study aimed to assess the prevalence and associated factors of depression among people with chronic skin disease at Boru Meda Hospital, Northeast Ethiopia.

METHODS

An institutional-based cross-sectional study was carried out from March 10- April 18, 2021, among a total of 381 people with chronic skin disease. The Patient Health Questioner-9 was used to assess depression. A logistic regression analysis model with an adjusted odds ratio was used to assess the strength of associations between the outcome and predictor variables. P-value < 0.05 was considered statistically significant.

RESULT

The magnitude of depression among people with chronic skin disease was 23.6% (95%Cl: 19.8%, 28.6%). We identified significantly increased odds of depression among participants with rural residence (AOR = 3.45, 95% CI: 1.64, 7.28), duration of illness above 5 years (AOR = 3.59, 95% CI: 1.31, 9.85), comorbid medical illness AOR = 2.51, 95% CI: 1.06, 5.98), family history of mental illness (AOR = 3.39, 95% CI: 1.11, 10.41), non-adherence to chronic skin disease medications (AOR = 3.53, 95% CI: 1.20, 10.41), low self-image (AOR = 4.69, 95% CI: 2.25, 9.77), and perceived stigma (AOR = 4.61, 95% CI: 2.14, 9.92).

CONCLUSION

Depression was common among patients with chronic skin diseases. This study has indicated a need for proper screening of depression in the current medical treatment of patients with chronic skin disease in Boru Meda Hospital, Northeast Ethiopia.

Racial, Ethnic, and Rural/Urban Disparities in HIV and Sexually Transmitted Infections in South Carolina

Examining the current incidence rates of HIV and STIs among racial and ethnic minority and rural residents is crucial to inform and expand initiatives and outreach efforts to address disparities and minimize the health impact of these diseases. A retrospective, cross-sectional study was conducted using Medicaid administrative claims data over a 2-year period (July 2019-June 2021) in South Carolina. Our main outcomes of interest were claims for chlamydia, gonorrhea, syphilis, and HIV. Any beneficiary with at least one claim for a relevant diagnosis throughout the study period was considered to have one of these diseases. Descriptive analyses and multivariable regression models were used to estimate the association between STIs, HIV, race and ethnicity, and rurality. Overall, 158,731 Medicaid beneficiaries had at least one medical claim during the study period. Most were female (86.6%), resided in urban areas (66.6%), and were of non-Hispanic Black race/ethnicity (42.6%). In total, 6.3% of beneficiaries had at least one encounter for chlamydia, 3.2% for gonorrhea, 0.5% for syphilis, and 0.8% for HIV. In multivariable models, chlamydia, gonorrhea, and HIV claims were significantly associated with non-Hispanic Black or other minority race/ethnicity compared to non-Hispanic white race/ethnicity. Rural residents were more likely to have a claim associated with chlamydia and gonorrhea compared to urban residents. The opposite was observed for syphilis and HIV. Providing updated evidence on disparities in STIs and HIV among racial/ethnic minority and rural populations in a southern state is essential for shaping state Medicaid policies to address health disparities.

A large-scale machine learning study of sociodemographic factors contributing to COVID-19 severity

Understanding sociodemographic factors behind COVID-19 severity relates to significant methodological difficulties, such as differences in testing policies and epidemics phase, as well as a large number of predictors that can potentially contribute to severity. To account for these difficulties, we assemble 115 predictors for more than 3,000 US counties and employ a well-defined COVID-19 severity measure derived from epidemiological dynamics modeling. We then use a number of advanced feature selection techniques from machine learning to determine which of these predictors significantly impact the disease severity. We obtain a surprisingly simple result, where only two variables are clearly and robustly selected-population density and proportion of African Americans. Possible causes behind this result are discussed. We argue that the approach may be useful whenever significant determinants of disease progression over diverse geographic regions should be selected from a large number of potentially important factors.

Changes in access to community health services among rural areas affected and unaffected by hospital closures between 2006 and 2018: A comparative interrupted time series study

PURPOSE

Recent studies suggest that Federally Qualified Health Centers (FQHC) may be expanding their provision of primary care in rural communities that experience a hospital loss. Whether these trends are different from rural areas not being affected by rural hospital closures is unknown.

METHODS

Data included Centers for Medicare and Medicaid Services Provider of Services files, the Cecil G. Sheps hospital closure database, and American Community Survey estimates. Changes in straight-line distances to the nearest FQHC and rural health clinic (RHC) were compared between areas affected and unaffected by a rural hospital closure in a matched case control study design using an interrupted time series model.

FINDINGS

There was no instantaneous percentage point increase in FQHC (2.41, 95% CI -0.79 to 5.60, P .140) or RHC (3.27, 95% CI -1.12 to 7.67, P .144) access following hospital closures compared to changes in access occurring in other rural areas. On average, rural ZIP codes affected by hospital closures exhibited a 0.84 percentage point increase in FQHC access over time (95% CI 0.40-1.28, P .000), but similar trends were also found within unaffected ZIP codes classified as small rural areas.

CONCLUSIONS

Rural areas impacted by hospital closures did not experience an increase in proximity to FQHCs or RHCs relative to changes in access occurring in other rural areas. Over time, most rural areas are seeing an increase in access to FQHCs and RHCs. Policies are needed to incentivize primary care providers to target geographic areas experiencing a hospital closure.

Targeted Telehealth Education Increases Interest in Using Telehealth among a Diverse Group of Low-Income Older Adults

Telehealth allows older adults to take control over their health and preventive care; however, they are less likely to use telehealth. Minority older adults use telehealth services less than their White counterparts. During COVID-19, the U.S. Medicare system allowed for telehealth delivery of Annual Wellness Visits, which are known to improve use of preventive services. To increase telehealth use, we targeted vulnerable, low-income, minority older adults and provided education to improve knowledge of and identify barriers to telehealth use. Ultimately, this could serve as a means of improving health and preventive care services. Participants resided at independent living facilities, low-income housing, and elders of the Native American coalition; N = 257. Participants received written education materials; a subset attended a 20-min presentation. In this quasi-experimental study, participants completed a pre-post survey. Results were analyzed using Chi-Squared and Fisher's Exact tests. Participants included 54 'in-person' and 203 'at-home' learners. Most were female (79%), single/widowed (51%), and white (65%). At baseline, 39% were familiar with telehealth; following education 73% stated understanding on accessing telehealth. Nearly 40% of participants said they would use telehealth in the future; a larger proportion of "in-person" (73%) learners were willing to use telehealth than "at-home" learners (41%) (p = 0.001). Divorced older adults and Blacks voiced greater likelihoods of using telehealth than their married/widowed and White counterparts, respectively (Χ2(3, N = 195) = 9.693, p = 0.02), (p = 0.01). This education program demonstrates an increase likelihood in health promotion among older adults by increasing confidence in accessing and future use of telehealth; therefore, we achieved our aim of promoting telehealth use and improving health promotion.

Disparities in Spatial Access to Emergency Surgical Services in the US

Importance

Hospitals with emergency surgical services provide essential care for a wide range of time-sensitive diseases. Commonly used measures of spatial access, such as distance or travel time, have been shown to underestimate disparities compared with more comprehensive metrics.

Objective

To examine population-level differences in spatial access to hospitals with emergency surgical capability across the US using enhanced 2-step floating catchment (E2SFCA) methods.

Design, Setting, and Participants

A cross-sectional study using the 2015 American Community Survey data. National census block group (CBG) data on community characteristics were paired with geographic coordinates of hospitals with emergency departments and inpatient surgical services, and hospitals with advanced clinical resources were identified. Spatial access was measured using the spatial access ratio (SPAR), an E2SFCA method that captures distance to hospital, population demand, and hospital capacity. Small area analyses were conducted to assess both the population with low access to care and community characteristics associated with low spatial access. Data analysis occurred from February 2021 to July 2022.

Main Outcomes and Measures

Low spatial access was defined by SPAR greater than 1.0 SD below the national mean (SPAR <0.3).

Results

In the 217 663 CBGs (median [IQR] age for CBGs, 39.7 [33.7-46.3] years), there were 3853 hospitals with emergency surgical capabilities and 1066 (27.7%) with advanced clinical resources. Of 320 million residents, 30.8 million (9.6%) experienced low access to any hospital with emergency surgical services, and 82.6 million (25.8%) to advanced-resource centers. Insurance status was associated with low access to care across all settings (public insurance: adjusted rate ratio [aRR], 1.21; 95% CI, 1.12-1.25; uninsured aRR, 1.58; 95% CI, 1.52-1.64). In micropolitan and rural areas, high-share (>75th percentile) Hispanic and other (Asian; American Indian, Alaska Native, or Pacific Islander; and 2 or more racial and ethnic minority groups) communities were also associated with low access. Similar patterns were seen in access to advanced-resource hospitals, but with more pronounced racial and ethnic disparities.

Conclusions and Relevance

In this cross-sectional study of access to surgical care, nearly 1 in 10 US residents experienced low spatial access to any hospital with emergency surgical services, and 1 in 4 had low access to hospitals with advanced clinical resources. Communities with high rates of uninsured or publicly insured residents and racial and ethnic minority communities in micropolitan and rural areas experienced the greatest risk of limited access to emergency surgical care. These findings support the use of E2SFCA models in identifying areas with low spatial access to surgical care and in guiding health system development.

Does Primary Care Availability Mediate the Relationship Between Rurality and Lower Life Expectancy in the United States?

INTRODUCTION

Rural counties in the United States have lower life expectancy than their urban counterparts and comprise the majority of primary care provider (PCP) shortage areas. We evaluated whether PCP availability mediates the relationship between rurality and lower life expectancy.

METHODS

We performed a mediation analysis on a panel dataset which included county-level estimates (N = 3103) for the years 2010, 2015, and 2017, and on a subset containing only rural counties (N = 1973), with life expectancy as the outcome variable, urbanity as the independent variable, and PCP density as the mediating variable. County-level socio-demographic data were included as covariates.

RESULTS AND CONCLUSIONS

PCP density mediated 10.1% of the relationship between urbanity and life expectancy in rural counties. Increasing PCP density in rural counties with PCP shortages to the threshold of being a non-shortage county (>1 physician/3500 population, as defined by the Health Resources and Services Administration) would be expected to increase mean life expectancy in the county by 26.1 days (95% confidence interval [CI]: 11.4, 49.3) and increasing it to the standards recommended by a Secretarial Negotiated Rulemaking Committee would be expected to increase mean life expectancy by 65.3 days (95% CI: 42.6, 87.5). PCP density is a meaningful mediator of the relationship between urbanity and life expectancy. The mediation effect observed was higher in rural counties compared to all counties. Understanding how PCP density may be increased in rural areas may be of benefit to rural life expectancy.

Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

BACKGROUND

Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.

OBJECTIVE

To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.

DESIGN

Patient self-report surveys at treatment initiation linked to medical records.

SETTING

Veterans Health Administration (VA) clinics nationally, 2018-2020.

PARTICIPANTS

A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) MAIN MEASURES: Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.

KEY RESULTS

More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ²₁=175.3, p<0.001). A total of 32.1% of patients who preferred (7-10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5-24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0-3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4-7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence.

CONCLUSIONS

Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.

Antihypertensive and Statin Medication Adherence Among Medicare Beneficiaries

INTRODUCTION

Medication adherence is important for optimal management of chronic conditions, including hypertension and hypercholesterolemia. This study describes adherence to antihypertensive and statin medications, individually and collectively, and examines variation in adherence by demographic and geographic characteristics.

METHODS

The 2017 prescription drug event data for beneficiaries with Medicare Part D coverage were assessed. Beneficiaries with a proportion of days covered ≥80% were considered adherent. Adjusted prevalence ratios were estimated to quantify the associations between demographic and geographic characteristics and adherence. Adherence estimates were mapped by county of residence using a spatial empirical Bayesian smoothing technique to enhance stability. Analyses were conducted in 2019‒2021.

RESULTS

Among the 22.5 million beneficiaries prescribed antihypertensive medications, 77.1% were adherent; among the 16.1 million prescribed statin medications, 81.9% were adherent; and among the 13.5 million prescribed antihypertensive and statin medications, 70.3% were adherent to both. Adherence varied by race/ethnicity: American Indian/Alaska Native (adjusted prevalence ratio=0.83, 95% confidence limit=0.82, 0.842), Hispanic (adjusted prevalence ratio=0.90, 95% confidence limit=0.90, 0.91), and non-Hispanic Black (adjusted prevalence ratio=0.87, 95% confidence limit=0.86, 0.87) beneficiaries were less likely to be adherent than non-Hispanic White beneficiaries. County-level adherence ranged across the U.S. from 25.7% to 88.5% for antihypertensive medications, from 36.0% to 93.8% for statin medications, and from 20.8% to 92.9% for both medications combined and tended to be the lowest in the southern U.S.

CONCLUSIONS

This study highlights opportunities for efforts to remove barriers and support medication adherence, especially among racial/ethnic minority groups and within the regions at greatest risk for adverse cardiovascular outcomes.

"Mothers are Medicine": U.S. Indigenous Media Emphasizing Indigenous Women's Roles in COVID-19 Coverage

As COVID-19 surged in 2020, non-Indigenous media had a chronic disease of its own: sparse pandemic news from Indian Country. Within this inadequate coverage, there was an erasure of sources: Indigenous women were missing. This study evaluates the role of gender in U.S. Indigenous news coverage during the early stage of the COVID-19 pandemic. In a qualitative thematic textual analysis, 161 Indigenous media news articles were analyzed to examine gendered news coverage themes from the time the United States instituted a nationwide quarantine until the autumn of 2020. U.S. Indigenous media amplified voices of the Indigenous women on the COVID-19 frontlines. This study focuses on Indigenous media as the benchmark for telling ethical diverse Indigenous community-focused stories, illustrating how women's voices led media coverage and amplified issues. U.S. tribes are often matriarchal. As Europeans wielded disease and genocide as extermination tactics on these communities, women's voices served as medicine to guide narratives to community solutions and healing. As such, this study seeks to add to current theoretical understanding of how Indigenous women's roles were portrayed in COVID-19 coverage.

Using Implementation Mapping to Ensure the Success of PrEP Optimization Through Enhanced Continuum Tracking (PrOTECT) AL-A Structural Intervention to Track the Statewide PrEP Care Continuum in Alabama

INTRODUCTION

Ending the HIV Epidemic initiatives provide a unique opportunity to use implementation scientific methods to guide implementation of evidence-based practices and evaluate their effectiveness in real-word settings to improve HIV inequities. This report demonstrates our use of Implementation Mapping (IM) to engage participating county health departments, AIDS services organizations, and community-based organizations in the development of a data dashboard to track the PrEP care continuum for the state of Alabama, an Ending the HIV Epidemic hotspot.

METHODS

Our project is guided by an overarching Implementation Research Logic Model and by the tenets of IM, a 5-step approach to support researchers and community partners in the systematic selection, development, and/or tailoring of implementation strategies to increase program adoption, implementation, and sustainability.

RESULTS

Step 1, the needs assessment, established baseline data elements for a PrEP care continuum for participating community-based organizations, AIDS services organizations, and the state health department as well as investigated their desire for data visualization and willingness to share data to inform initiatives to improve PrEP access. Step 2 identified adaptability, relative advantage, and complexity as determinants of intervention adoption. Based on findings from steps 1 and 2, the investigators and community partners determined to move forward with development of a data dashboard. Step 3 identified the following implementation strategies to support a dashboard, including development of educational materials, synchronous and asynchronous training, technical assistance, and improved record systems.

DISCUSSION

Using IM supports community-engaged researchers in designing strategies to end the epidemic that are context-specific and more impactful in real-word settings.

Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers

Importance

Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity.

Objective

To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers.

Design, Setting, and Participants

This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021.

Exposures

Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index.

Main Outcomes and Measures

Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity.

Results

The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% - 17.6% = 0.7%) plus those identifying as Black (21.9% - 17.6% = 4.3%) by more than 2-fold (28.0% - 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality.

Conclusions and Relevance

Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.

Association between increasing agricultural use of 2,4-D and population biomarkers of exposure: findings from the National Health and Nutrition Examination Survey, 2001-2014

BACKGROUND

2,4-Dichlorophenoxyacetic acid (2,4-D) is one of the most extensively used herbicides in the United States. In 2012, 2,4-D was the most widely used herbicide in non-agricultural settings and the fifth most heavily applied pesticide in the US agricultural sector. The objective of this study was to examine trends in 2,4-D urinary biomarker concentrations to determine whether increases in 2,4-D application in agriculture are associated with increases in biomonitoring levels of urine 2,4-D.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) with available urine 2,4-D biomarker measurements from survey cycles between 2001 and 2014 were utilized. Urine 2,4-D values were dichotomized using the highest limit of detection (LOD) across all cycles (0.40 μg/L or 0.4 ppb). Agricultural use of 2,4-D was estimated by compiling publicly available federal and private pesticide application data. Logistic regression models adjusted for confounders were fitted to evaluate the association between agricultural use of 2,4-D and urine 2,4-D level above the dichotomization threshold.

RESULTS

Of the 14,395 participants included in the study, 4681 (32.5%) had urine 2,4-D levels above the dichotomization threshold. The frequency of participants with high 2,4-D levels increased significantly (p < .0001), from a low of 17.1% in 2001-2002 to a high of 39.6% in 2011-2012. The adjusted odds of high urinary 2,4-D concentrations associated with 2,4-D agricultural use (per ten million pounds applied) was 2.268 (95% CI: 1.709, 3.009). Children ages 6-11 years (n = 2288) had 2.1 times higher odds of having high 2,4-D urinary concentrations compared to participants aged 20-59 years. Women of childbearing age (age 20-44 years) (n = 2172) had 1.85 times higher odds than men of the same age.

CONCLUSIONS

Agricultural use of 2,4-D has increased substantially from a low point in 2002 and it is predicted to increase further in the coming decade. Because increasing use is likely to increase population level exposures, the associations seen here between 2,4-D crop application and biomonitoring levels require focused biomonitoring and epidemiological evaluation to determine the extent to which rising use and exposures cause adverse health outcomes among vulnerable populations (particularly children and women of childbearing age) and highly exposed individuals (farmers, other herbicide applicators, and their families).

Socio-Spatial Disparities in County-Level Availability of Aging and Disability Services Organizations

Aging and disability services are essential for supporting older adults in living independently in their homes and communities as they age. Applying theoretical perspectives of community gerontology and spatial inequality, we use county-level data (N=3142) from the National Neighborhood Data Archive (NaNDA) and the American Community Survey to explore if and how availability of aging and disability services organizations varies across the rural-urban continuum and across compositional characteristics of counties. Results show that rural counties are significantly more likely to be aging and disability services deserts. Stratified models show that poverty rates and relative shares of non-Hispanic Blacks are positively associated with greater odds of aging and disability services deserts across rural and urban counties, but divergent findings appear for county-level shares of Hispanics. These findings are discussed as well as implications for research, policy, and practice on equitable access to aging and disability services.

Barriers to and Facilitators of Automated Patient Self-scheduling for Health Care Organizations: Scoping Review

BACKGROUND

Appointment management in the outpatient setting is important for health care organizations, as waits and delays lead to poor outcomes. Automated patient self-scheduling of outpatient appointments has demonstrable advantages in the form of patients' arrival rates, labor savings, patient satisfaction, and more. Despite evidence of the potential benefits of self-scheduling, the organizational uptake of self-scheduling in health care has been limited.

OBJECTIVE

The objective of this scoping review is to identify and to catalog existing evidence of the barriers to and facilitators of self-scheduling for health care organizations.

METHODS

A scoping review was conducted by searching 4 databases (PubMed, CINAHL, Business Source Ultimate, and Scopus) and systematically reviewing peer-reviewed studies. The Consolidated Framework for Implementation Research was used to catalog the studies.

RESULTS

In total, 30 full-text articles were included in this review. The results demonstrated that self-scheduling initiatives have increased over time, indicating the broadening appeal of self-scheduling. The body of literature regarding intervention characteristics is appreciable. Outer setting factors, including national policy, competition, and the response to patients' needs and technology access, have played an increasing role in influencing implementation over time. Self-scheduling, compared with using the telephone to schedule an appointment, was most often cited as a relative advantage. Scholarly pursuit lacked recommendations related to the framework's inner setting, characteristics of individuals, and processes as determinants of implementation. Future discoveries regarding these Consolidated Framework for Implementation Research domains may help detect, categorize, and appreciate organizational-level barriers to and facilitators of self-scheduling to advance knowledge regarding this solution.

CONCLUSIONS

This scoping review cataloged evidence of the existence, advantages, and intervention characteristics of patient self-scheduling. Automated self-scheduling may offer a solution to health care organizations striving to positively affect access. Gaps in knowledge regarding the uptake of self-scheduling by health care organizations were identified to inform future research.

Evaluating disparities in access to obstetric services for American Indian women across Montana

PURPOSE

Pregnant women across the rural United States have increasingly limited access to obstetric care, especially specialty care for high-risk women and infants. Limited research focuses on access for rural American Indian/Alaskan Native (AIAN) women, a population warranting attention given persistent inequalities in birth outcomes.

METHODS

Using Montana birth certificate data (2014-2018), we examined variation in travel time to give birth and access to different levels of obstetric care (i.e., the proportion of individuals living within 1- and 2-h drives to facilities), by rurality (Rural-Urban Continuum Code) and race (White and AIAN people).

FINDINGS

Results point to limited obstetric care access in remote rural areas in Montana, especially higher-level specialty care, compared to urban or urban-adjacent rural areas. AIAN women traveled significantly farther than White women to access care (24.2 min farther on average), even compared to White women from similarly rural areas (5-13 min farther, after controlling for sociodemographic characteristics, risk factors, and health care utilization). AIAN women were 20 times more likely to give birth at a hospital without obstetric services and had less access to complex obstetric care. Poor access was particularly pronounced among reservation-dwelling AIAN women.

CONCLUSIONS

It is imperative to consider racial disparities and health inequities underlying poor access to obstetric services across rural America. Current federal policies aim to reduce maternity care professional shortages. Our findings suggest that racial disparities in access to complex obstetric care will persist in Montana unless facility-level infrastructure is also expanded to reach areas serving AIAN women.

Rural Latino health and the built environment: a systematic review

Objective: This study systematically reviewed literature examining the influence of the rural built environment on Latinos' health outcomes and behaviour in the United States. A secondary aim of the study was to identify strategies developed to address challenges in the rural built environment affecting Latinos' health.Design: This study followed the reporting guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Articles included in the final analysis clearly linked Latino health outcomes to characteristics of the rural built environment.Results: Of the nearly 2,500 articles identified in the initial search, the final review included approximately 146 full-text sources. The majority of the articles focused on aspects of Latinos' physical (n = 68), behavioural (n = 43), and mental health (n = 23).Conclusions: Rural Latino neighbourhoods in the United States possess limited access to health care, internet, transportation, and recreation infrastructure, which negatively impacts health outcomes and behaviours. Strategies developed to mitigate these issues include but are not limited to: the use of telecommunications to distribute health information; the use of community health workers and mobile clinics to increase awareness and availability of select health services; the use of worksite trainings and adaptations to the workplace; and the promotion of safety net programmes, such as the Supplemental Nutrition Programme for Women, Infants and Children (WIC). This review supports the need for a more robust research agenda documenting the health experiences of rural Latinos of various nationalities, age groups, and genders.

Disparities in Care Experienced by Older Hispanic Medicare Beneficiaries in Urban and Rural Areas

BACKGROUND

Hispanic older adults face substantial health disparities compared with non-Hispanic-White (hereafter "White") older adults. To the extent that these disparities stem from cultural and language barriers faced by Hispanic people, they may be compounded by residence in rural areas.

OBJECTIVE

The objective of this study was to investigate possible interactions between Hispanic ethnicity and rural residence in predicting the health care experiences of older adults in the United States, and whether disparities in care for rural Hispanic older adults differ in Medicare Advantage versus Medicare Fee-for-Service.

SUBJECTS

Medicare beneficiaries age 65 years and older who responded to the 2017-2018 nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

METHODS

We fit a series of linear, case-mix-adjusted models predicting Medicare CAHPS measures of patient experience (rescaled to a 0-100 scale) from ethnicity, place of residence, and Medicare coverage type.

RESULTS

In all residential areas, Hispanic beneficiaries reported worse experiences with getting needed care (-3 points), getting care quickly (-4 points), and care coordination (-1 point) than White beneficiaries (all P's<0.001). In rural areas only, Hispanic beneficiaries reported significantly worse experiences than White beneficiaries on doctor communication and customer services (-3 and -9 points, respectively, P<0.05). Tests of a 3-way interaction between ethnicity, rural residence, and coverage type were nonsignificant.

CONCLUSIONS

There is a need to improve access to care and care coordination for Hispanic beneficiaries overall and doctor-patient communication and customer service for rural Hispanic beneficiaries. Strategies for addressing deficits faced by rural Hispanics may involve cultural competency training and provision of language-appropriate services for beneficiaries (perhaps as telehealth services).

Telemedicine in a primary care clinic in Fairbanks, Alaska: Not a magic bullet for providing treatment during COVID-19

Stay-at-home orders due to the COVID-19 pandemic have increased patients’ reliance on virtual physician visits, via telemedicine. Telemedicine has benefits of use during the pandemic and has benefits outside of the pandemic. It is underutilized in certain types of medical organizations, providers, and among specific populations in the United States. It is important to understand the barriers to incorporating telemedicine effectively in the areas that it is underutilized, especially in rural locations. The researcher discussed the telemedicine expansion for two family practice doctors in Fairbanks, Alaska (AK). The family practice doctors experienced barriers that partially echo what has been stated in research. Research suggests that changes to Medicare and Medicaid telemedicine policies may not be enough to address these barriers. Other supports to expand telemedicine where it is needed includes providing more incentives to providers, waivers from insurance companies for patients to purchase equipment, and more education to patients about when, how, and where to receive telemedicine. More supports need to be provided to those underserved by telemedicine, especially for clients who are on Medicaid, living in low-income areas, and/or living in rural locations.

Health and Poverty of Rural Children: An Under-Researched and Under-Resourced Vulnerable Population

Nearly 1 in 5 children in the United States live in rural areas. Rural children experience health and health care disparities compared to their urban peers and represent a unique and vulnerable pediatric patient population. Important disparities exist in all-cause mortality, suicide, firearm-related unintentional injury, and obesity. Rural children experience decreased availability and accessibility of primary care and specialty care (especially mental health care) due to a decreased number of health care providers as well as geographical and transportation-related barriers. Other geographic and socioeconomic determinants, especially concerning poverty and substandard housing conditions, are likely important contributors to the observed health disparities. Increased funding for research focused on rural populations is needed to provide innovative solutions for the unique health needs of rural children. Policy changes positioned to correct the trajectory of poor health among children should consider the needs of rural children as an under-researched and under-resourced vulnerable population.

Impact of COVID-19 on cervical cancer screening: Challenges and opportunities to improving resilience and reduce disparities

The COVID-19 pandemic has a major impact on a wide range of health outcomes. Disruptions of elective health services related to cervical screening, management of abnormal screening test results, and treatment of precancers, may lead to increases in cervical cancer incidence and exacerbate existing health disparities. Modeling studies suggest that a short delay of cervical screening in subjects with previously negative HPV results has minor effects on cancer outcomes, while delay of management and treatment can lead to larger increases in cervical cancer. Several approaches can mitigate the effects of disruption of cervical screening and management. HPV-based screening has higher accuracy compared to cytology, and a negative HPV result provides longer reassurance against cervical cancer; further, HPV testing can be conducted from self-collected specimens. Self-collection expands the reach of screening to underserved populations who currently do not participate in screening. Self-collection and can also provide alternative screening approaches during the pandemic because testing can be supported by telehealth and specimens collected in the home, substantially reducing patient-provider contact and risk of COVID-19 exposure, and also expanding the reach of catch-up services to address backlogs of screening tests that accumulated during the pandemic. Risk-based management allows prioritizing management of patients at highest risk of cervical cancer while extending screening intervals for those at lowest risk. The pandemic provides important lessons for how to make cervical screening more resilient to disruptions and how to reduce cervical cancer disparities that may be exacerbated due to disruptions of health services.

Value-Based Payment: What Does It Mean for Nurses?

Among the many lessons that have been reinforced by the SARS-COVID-19 pandemic is the failure of our current fee-for-service health care system to either adequately respond to patient needs or offer financial sustainability. This has enhanced bipartisan interest in moving forward with value-based payment reforms. Nurses have a rich history of innovative care models that speak to their potential centrality in delivery system reforms. However, deficits in terms of educational preparation, and in some cases resistance, to considering cost alongside quality, has hindered the profession's contribution to the conversation about value-based payments and their implications for system change. Addressing this deficit will allow nurses to more fully engage in redesigning health care to better serve the physical, emotional, and economic well-being of this nation. It also has the potential to unleash nurses from the tethers of a fee-for-service system where they have been relegated to a labor cost and firmly locate nurses in a value-generating role. Nurse administrators and educators bear the responsibility for preparing nurses for this next chapter of nursing.

Overall Work and Practice Satisfaction of Licensed Clinical Social Workers in the National Health Service Corps Loan Repayment Program

Little is known about the job satisfaction of licensed clinical social workers (LCSWs) participating in the National Health Service Corps (NHSC) federal Loan Repayment Program (LRP). Employee satisfaction in organizations is important for organizational well-being and to decrease turnover. A satisfied NHSC LCSW workforce is also important given the array of services it provides, especially in rural and underserved areas. This study examined the work satisfaction of 386 LCSWs participating in the NHSC LRP in 21 states. Rural upbringing, being older than 40 years, and a higher salary were significantly associated with overall work and practice satisfaction. In addition, satisfaction with administration, staff and the practices' linkages to other health providers, the mission of the practice, and connection with patients were strongly associated with overall work and practice satisfaction. To our knowledge, this is the first study to examine the work and practice satisfaction of LCSWs participating in the NHSC LRP, and our findings have the potential to inform the NHSC's strategies in managing and retaining LCSWs.

Assessment of Coronavirus Disease 2019 Infection and Mortality Rates Among Nursing Homes With Different Proportions of Black Residents

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has disproportionately impacted nursing homes (NHs) with large shares of Black residents. We examined the associations between the proportion of Black residents in NHs and COVID-19 infections and deaths, accounting for structural bias (operationalized as county-level factors) and stratifying by urbanicity/rurality.

DESIGN

This was a cross-sectional observational cohort study using publicly available data from the LTCfocus, Centers for Disease Control and Prevention Long-Term Care Facility COVID-19 Module, and the NYTimes county-level COVID-19 database. Four multivariable linear regression models omitting and including facility characteristics, COVID-19 burden, and county-level fixed effects were estimated.

SETTING AND PARTICIPANTS

In total, 11,587 US NHs that reported data on COVID-19 to the Centers for Disease Control and Prevention and had data in LTCfocus and NYTimes from January 20, 2020 through July 19, 2020.

MEASURES

Proportion of Black residents in NHs (exposure); COVID-19 infections and deaths (main outcomes).

RESULTS

The proportion of Black residents in NHs were as follows: none= 3639 (31.4%), <20% = 1020 (8.8%), 20%-49.9% = 1586 (13.7%), ≥50% = 681 (5.9%), not reported = 4661 (40.2%). NHs with any Black residents showed significantly more COVID-19 infections and deaths than NHs with no Black residents. There were 13.6 percentage points more infections and 3.5 percentage points more deaths in NHs with ≥50% Black residents than in NHs with no Black residents (P < .001). Although facility characteristics explained some of the differences found in multivariable analyses, county-level factors and rurality explained more of the differences.

CONCLUSIONS AND IMPLICATIONS

It is likely that attributes of place, such as resources, services, and providers, important to equitable care and health outcomes are not readily available to counties where NHs have greater proportions of Black residents. Structural bias may underlie these inequities. It is imperative that support be provided to NHs that serve greater proportions of Black residents while considering the rurality of the NH setting.

Disparities in Health Care Access and Utilization at the Intersections of Urbanicity and Sexual Identity in California

Purpose: The aim was to examine differences in health care access at the intersections of urbanicity and sexual identity in California. Methods: We used the 2014-2017 Adult California Health Interview Survey paired with the sexual orientation special use research file to create dummy groups representing each dimension of urbanicity and sexual identity to compare access to health care outcomes. We calculated unadjusted proportions and estimated adjusted odds ratios of each dimension relative to urban heterosexual people using logistic regressions. Results: Relative to urban heterosexual people, urban gay/lesbian people had 1.651 odds of using the emergency room (ER). Urban bisexual people had 1.429 odds of being uninsured, 1.575 odds of delaying prescriptions, and 1.907 odds of using the ER. Rural bisexual people experienced similar access barriers having 1.904 odds of uninsurance and 2.571 odds of using the ER. Conclusions: Our study findings demonstrated disparate access to health care across sexual orientation and rurality. The findings are consistent with literature that suggests urban and rural sexual minority people experience health care differently and demonstrate that bisexual people experience health care differently than gay/lesbian people. These findings warrant further study to examine how social identities, such as race/ethnicity, interact with sexual orientation to determine health care access. Furthermore, these findings demonstrate the need to emphasize the health care access needs of sexual minority people in both rural and urban areas to eliminate health care access disparities.

The Intersection of Rural Residence and Minority Race/Ethnicity in Cancer Disparities in the United States

One in every twenty-five persons in America is a racial/ethnic minority who lives in a rural area. Our objective was to summarize how racism and, subsequently, the social determinants of health disproportionately affect rural racial/ethnic minority populations, provide a review of the cancer disparities experienced by rural racial/ethnic minority groups, and recommend policy, research, and intervention approaches to reduce these disparities. We found that rural Black and American Indian/Alaska Native populations experience greater poverty and lack of access to care, which expose them to greater risk of developing cancer and experiencing poorer cancer outcomes in treatment and ultimately survival. There is a critical need for additional research to understand the disparities experienced by all rural racial/ethnic minority populations. We propose that policies aim to increase access to care and healthcare resources for these communities. Further, that observational and interventional research should more effectively address the intersections of rurality and race/ethnicity through reduced structural and interpersonal biases in cancer care, increased data access, more research on newer cancer screening and treatment modalities, and continued intervention and implementation research to understand how evidence-based practices can most effectively reduce disparities among these populations.

Rural representation of the surveillance, epidemiology, and end results database

PURPOSE

SEER data are widely used to study rural-urban disparities in cancer. However, no studies have directly assessed how well the rural areas covered by SEER represent the broader rural United States.

METHODS

Public data sources were used to calculate county level measures of sociodemographics, health behaviors, health access and all cause cancer incidence. Driving time from each census tract to nearest Commission on Cancer certified facility was calculated and analyzed in rural SEER and non-SEER areas.

RESULTS

Rural SEER and non-SEER counties were similar with respect to the distribution of age, race, sex, poverty, health behaviors, provider density, and cancer screening. Overall cancer incidence was similar in rural SEER vs non-SEER counties. However, incidence for White, Hispanic, and Asian patients was higher in rural SEER vs non-SEER counties. Unadjusted median travel time was 53 min (IQR 34-82) in rural SEER tracts and 54 min (IQR 35-82) in rural non-SEER census tracts. Linear modeling showed shorter travel times across all levels of rurality in SEER vs non-SEER census tracts when controlling for region (Large Rural: 13.4 min shorter in SEER areas 95% CI 9.1;17.6; Small Rural: 16.3 min shorter 95% CI 9.1;23.6; Isolated Rural: 15.7 min shorter 95% CI 9.9;21.6).

CONCLUSIONS

The rural population covered by SEER data is comparable to the rural population in non-SEER areas. However, patients in rural SEER regions have shorter travel times to care than rural patients in non-SEER regions. This needs to be considered when using SEER-Medicare to study access to cancer care.

Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities

Telehealth programs have long held promise for addressing rural health disparities perpetuated by inadequate healthcare access. The COVID-19 (coronavirus disease 2019) pandemic and accompanying social distancing measures have hastened the implementation of telehealth programs in hospital systems around the globe. Here, we provide specific examples of telehealth efforts that have been implemented in a large rural healthcare system in response to the pandemic, and further describe how the massive shift to telehealth and reliance on virtual connections in these times of social isolation may impact rural health disparities for those without access to necessary broadband to deploy digital technologies. Finally, we provide recommendations for researchers and policymakers to ensure that telehealth initiatives do not amplify existing health disparities experienced by those living in rural communities.