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Purpose Although tablet computers offer advantages in data collection over traditional paper-and-pencil methods, little research has examined whether the 2 formats yield similar responses, especially with underserved populations. We compared the 2 survey formats and tested whether participants' responses to common health questionnaires or perceptions of usability differed by survey format. We also tested whether we could replicate established paper-and-pencil findings via tablet computer. Methods We recruited a sample of low-income community members living in the rural southern United States. Participants were 170 residents (black = 49%; white = 36%; other races and missing data = 15%) drawn from 2 counties meeting Florida's state statutory definition of rural with 100 persons or fewer per square mile. We randomly assigned participants to complete scales (Center for Epidemiologic Studies Depression Inventory and Regulatory Focus Questionnaire) along with survey format usability ratings via paper-and-pencil or tablet computer. All participants rated a series of previously validated posters using a tablet computer. Finally, participants completed comparisons of the survey formats and reported survey format preferences. Findings Participants preferred using the tablet computer and showed no significant differences between formats in mean responses, scale reliabilities, or in participants' usability ratings. Conclusions Overall, participants reported similar scales responses and usability ratings between formats. However, participants reported both preferring and enjoying responding via tablet computer more. Collectively, these findings are among the first data to show that tablet computers represent a suitable substitute among an underrepresented rural sample for paper-and-pencil methodology in survey research. [ABSTRACT FROM AUTHOR]

Purpose: Rural older people living with HIV (PLH) in the United States are a population of growing size and significance. A better understanding of factors associated with quality of life (QOL), depressive symptoms, and stress in this population—especially modifiable factors—could inform future interventions. Methods: Online or on paper, we surveyed 446 PLH aged 50+ residing in rural counties across the United States (Mage = 56, 67% male, 67% White, and 23% Black). Associations between social support, HIV stigma, satisfaction with medical care, discrimination in health care settings, and structural barriers and health‐related QOL, depressive symptoms, and perceived stress were assessed using multiple linear regressions. Findings: Controlling for demographics, greater social support was associated with better QOL, fewer depressive symptoms, and less stress. Greater HIV stigma was associated with more depressive symptoms and stress. Satisfaction with care was associated with better QOL and less stress. Discrimination in medical settings was associated with lower QOL and more depressive symptoms and stress. Finally, experiencing more structural barriers was associated with lower QOL and more depressive symptoms and stress. Conclusions: In addition to engagement in care and viral suppression, QOL and mental health are also critical considerations for rural older PLH. Increasing social support, reducing or providing skills to cope with HIV stigma, improving quality of care, reducing discrimination and stigma in medical settings, and reducing or mitigating the impact of structural barriers present potential targets for interventions aiming to improve the well‐being of older rural PLH. [ABSTRACT FROM AUTHOR]

Purpose: Housing is essential to health. Governmental rental assistance is one way to increase access to affordable housing, but little is known about how it varies by rural/urban location. This paper seeks to address that gap by examining rural/urban and within‐rural differences in receipt of rental assistance, with particular attention differences by health and disability. Methods: We used data from the 2021 National Health Interview Survey (n = 28,254) to conduct bivariate analyses to identify significant differences in receipt of rental assistance by rural/urban location. We then conducted logistic regression analyses to generate odds ratios of receiving rental assistance, adjusting for self‐rated health, disability, sociodemographic characteristics, and the US Census region. Findings: When limiting the sample to those who rent (20.6% of rural residents and 29.6% of urban residents), rural residents were nearly 5 percentage points more likely to receive rental assistance (13.1% vs 8.2%, P<.001). Rural recipients of rental assistance were more likely to have a disability than urban residents (27.9% vs 20.3%, P<.05) and were more likely to report fair/poor health (41.6% vs 31.4%, P<.05). Conclusions: Rural residents are less likely to rent their homes, but, among those who rent, they are more likely to receive governmental rental assistance. This may be reflective of the greater need for rental assistance among rural residents, who were in poorer health and of lower socioeconomic status than urban renters. As housing is essential to good health, policy attention must prioritize addressing a persistent and growing need for affordable housing in rural and urban areas alike. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to examine the impact of rural hospital closures on age‐adjusted hospitalization rates for ambulatory care sensitive condition (ACSC) and emergency care sensitive condition (ECSC) and associated outcomes, such as length of stay and in‐hospital mortality in hospital service areas (HSAs) that utilized the closed hospital. Methods: We used the State Inpatient Data from the Healthcare Cost and Utilization Project for 9 states from 2010 to 2017 and classified admissions as ACSC or ECSC. We compared age‐adjusted admission rates and length of stay (LOS) for ACSC and ECSC rates and age adjusted in‐hospital mortality rate for ECSC among rural ZIP codes in HSAs with a closure to rural ZIP codes in HSAs without closures. We used propensity score‐weighted regression analysis and event study design. Findings: Findings suggest that ACSC admission rates started to increase right before the closure. However, this increase levels off 2 years after closure. LOS for ACSC significantly decreased almost a year after closure. ECSC admissions showed a significant decrease for a few quarters 1 year before the closure. Conclusions: Rural hospital closures were associated with increase in ACSC admissions right before closure and for nearly 2 years post closure as well as decrease in ECSC admissions before closure. As rural hospitals continue to close, efforts to ensure communities affected by these closures maintain access to primary health care may help eliminate increases in costly preventable hospital admissions for ACSC while ensuring access for emergency care services. [ABSTRACT FROM AUTHOR]

Purpose: Rural residents have higher obesity rates and need access to treatment. Travel burden may limit use and effectiveness of clinic‐based behavioral weight loss treatment, which includes frequent visits. This paper examines the impact of travel distance and time on visit attendance and weight loss during a 2‐year cluster randomized trial. Methods: Thirty‐six primary care practices were randomized to 1 of 3 methods of providing behavioral weight loss counseling: individual clinic visits, group clinic visits, or group phone visits. Participants in the clinic visit conditions were included in this secondary analysis (n = 875). Travel distance and time was measured using ArcGIS and categorized as <15 miles (and minutes) or ≥15 miles (and minutes). Percent visit attendance and percent weight loss were measured 6 and 24 months. Findings: Participants traveling ≥15 miles (n = 211) had lower attendance than those traveling <15 miles (n = 664) for individual clinic visits, both in the first 6 months (81.4% vs 89.1%, respectively; P =.005) and between 7 and 24 months (52.8% vs 61.6%, respectively; P =.02). Travel time revealed similar findings. Neither travel distance nor time had an effect on attendance to group clinic visits. Travel distance and time were not significantly associated with weight loss for either individual or group visits. Conclusion: Travel burden to clinics was associated with visit attendance for individual visits but not for group visits and was not significantly associated with weight loss. Assessment of travel burden as a potential barrier to clinic‐based weight loss interventions should be based on local empirical data. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to examine differences between urban and rural primary care clinics in the use of colorectal cancer (CRC) screening methods and evidence‐based interventions to promote CRC screening. Methods: This was a cross‐sectional survey of primary care clinics in Nebraska. Surveys in paper form were sent out and followed up with telephone interviews to nonrespondents. Of the 375 facilities, 263 (70.1%) responded to the survey. Findings: Over 30% of urban clinics indicated that 80% or more of their patients were meeting the CRC guidelines compared to 18.3% of rural clinics (P =.03). Rural clinics were more likely than urban clinics to prefer the use of colonoscopy alone or in combination with stool tests (P =.02). The most common interventions for CRC screening included one‐on‐one patient education and use of computer‐based pop‐ups to remind providers. Conclusions: In conclusion, we found some important differences between rural and urban primary care clinics in the implementation of CRC screening. Given that there is evidence for differences in preference for CRC screening methods (colonoscopy vs stool‐based tests) between rural and urban community members, it is important to assess the effectiveness of different types of CRC screening interventions by comparing rural and urban primary care clinic patient populations. [ABSTRACT FROM AUTHOR]

Purpose: Culturally competent health care has led to increasing interest in how patients' identities influence the management of their health. The ways rural patients with advanced cancer process emotions and cope with their disease may be influenced by their rural context. The aims for this study were to (1) describe the emotions rural cancer patients experience, (2) describe how rural cancer patients manage their emotions within their rural context, and (3) interlace the themes related to coping with emotions. Methods: This paper is a subanalysis of a larger project focused on symptom management among rural patients living with advanced cancer. Using a qualitative descriptive design, authors read and coded patient interview transcripts to extract key perspectives related to managing emotions within a rural context. Findings: Sixteen participants, 10 men and 6 women, with a mean age of 68.75 years completed this study. Participants described a spectrum of emotional experiences. Some participants reported no distress, and some described high levels of distress. While previous writers described low levels of religious coping among rural patients, participants in this study often named their faith/spirituality as a major source of emotional coping. Participants also galvanized their social support network, particularly those in their religious community. Finally, participants in this study reported the use of medication as a last resort. Conclusion: Results from this study might be influenced from cultural variables found in the rural community; specifically, religiosity and close social networks. Future interventions need to be tailored to the unique responses of rural patients. [ABSTRACT FROM AUTHOR]

Purpose: Despite the efforts of numerous medical schools to produce rural physicians, many rural communities in the United States still experience physician shortages. This study describes the current landscape of rural efforts in US undergraduate medical education and catalogs medical school characteristics and activities that evidence has suggested, and that many experts in rural medical education believe, may result in more graduates choosing rural practice. Methods: This is a descriptive study of publicly available and rurally relevant characteristics of all 182 allopathic and osteopathic medical schools operating in the 50 states and the District of Columbia in 2016, with rural program information for these schools updated in 2019. The authors constructed a "rural program" definition in order to systematically catalog coordinated and strategic medical school efforts to produce a rural physician workforce. Findings: Few (8.2%) medical schools expressed an explicit commitment to producing rural physicians in public mission statements. However, most (64.8%) provided rural clinical experiences and many demonstrated their commitment in other ways. Only 39 (21.4%) did so through a formal rural program. Conclusions: In establishing an explicit rural program definition and documenting other markers of rural commitment, this paper provides a baseline for future studies of rural workforce production and medical school investment in these programs, activities, and personnel. Demonstrating the effectiveness of schools' rural physician education efforts will require collaboration across institutions and more intensive evaluations of programs involving students who, though relatively few in number, have great potential for contributing to the health of rural communities across the nation. [ABSTRACT FROM AUTHOR]

Purpose: In 2018, the Centers for Disease Control and Prevention (CDC) released an evidence‐based guideline on pediatric mild traumatic brain injury (mTBI) to educate health care providers on best practices of mTBI diagnosis, prognosis, and management/treatment. As residents living in rural areas have higher rates of mTBI, and may have limited access to care, it is particularly important to disseminate the CDC guideline to rural health care providers. The purpose of this paper is to describe rural health care providers' experience with pediatric mTBI patients and their perceptions on incorporating the guideline recommendations into their practice. Method: Interviews with 9 pediatric rural health care providers from all US regions were conducted. Interview transcripts were coded and analyzed for themes for each of the main topic areas covered in the interview guide. Findings: Common causes of mTBI reported by health care providers included sports and all‐terrain vehicles. While health care providers found the guideline recommendations to be helpful and feasible, they reported barriers to implementation, such as lack of access to specialists. To help with uptake of the CDC guideline, they suggested the development of concise implementation tools that can be referenced quickly, integrated into electronic health record‐based systems, and that are customized by visit type and health care setting (eg, initial vs follow‐up visits and emergency department vs primary care visits). Conclusion: Length, accessibility, and usability are important considerations when designing clinical tools for busy rural health care providers caring for pediatric patients with mTBI. Customized information, in both print and digital formats, may help with uptake of best practices. [ABSTRACT FROM AUTHOR]

Objectives: We examined the relationship between suicide risk and disability status, as well as risk and protective factors, adjusting for demographic characteristics, among students attending 22 Tribal Colleges and Universities (TCU; 20 rural and 2 urban) across the United States in fall 2015 and 2016. Methods: Tribal college students (N = 3,239) participated in a cross‐sectional online or paper survey assessing alcohol use patterns and mental health outcomes, yielding a response rate of 31.3%. Results: Of the students surveyed, 8.8% indicated moderate or high suicide risk. Hearing impairment was significantly associated with moderate/high suicide risk (OR = 2.11; 1.24‐3.61, P =.006), as was vision impairment (OR = 3.03; 1.92‐4.77, P <.001), having a physical/mental/or emotional condition (OR = 2.12; 1.75‐2.57, P <.001), experiencing critical appraisal (OR = 1.30; 1.24‐1.36, P <.001), and experiencing critical isolation (OR = 1.83; 1.66‐2.01, P <.001). Scoring high on resilience (OR = 0.93; 0.92‐0.95, P <.001), reporting higher emotional social support (OR = 0.75; 0.70‐0.79, P <.001), and reporting higher levels of instrumental social support (OR = 0.69, 0.62‐0.76, P <.001) were significantly associated with lower suicide risk. Conclusions: Students attending tribal colleges who experience hearing impairment, sight impairment, or a physical/emotional/mental condition have a greater risk of suicidality. Students experiencing critical appraisal and critical isolation may benefit from behavioral health interventions to reframe these experiences and develop resiliency skills. Developing avenues of emotional and instrumental social support within TCU settings offers key protective factors to buffer the risk of suicidality. Examining additional ways to build resiliency may also offer protection from suicide risk in this population. [ABSTRACT FROM AUTHOR]

Background: Rural and underserved communities often struggle to provide access to specialized health care, including sexual assault care. Telehealth is an effective solution for providing access to an array of specialized health care services. Prior sexual assault telehealth programs have provided evidence that telehealth is a feasible and acceptable solution. However, there is scant information about program development and considerations in the literature to guide those who may seek to implement a sexual assault telehealth program in their communities. Purpose: The purpose of this paper is to describe the Sexual Assault Forensic Examination Telehealth (SAFE‐T) Center—a nurse‐led model for providing comprehensive, high‐quality sexual assault care in rural and underserved communities recently implemented at 3 hospitals in rural Pennsylvania. Methods: Using the program's logic model, we present our community‐engaged approach to the development and implementation phases of the SAFE‐T Center. Findings: We first describe how academic researchers partnered with multiple stakeholders to form a statewide advisory board and articulated a vision and mission for the SAFE‐T Center that meets the needs of local communities. We then describe the overall design of the model, how it was informed by this academic‐community partnership, and how each element relates to anticipated outcomes. We also present our plans for program evaluation, expansion, and sustainability. Conclusion: This detailed description of collaborative partnership, coalition‐building, program design and implementation can serve as a guide for hospitals and health systems seeking to implement telehealth programs to improve the care provided to survivors of sexual assault. [ABSTRACT FROM AUTHOR]

Purpose: Opioid overdose death rates rose 36% from 2015 to 2016 in Missouri, indicating a worsening of the opioid overdose epidemic. To better understand urban and rural differences in nonfatal opioid overdoses treated in Missouri emergency departments, this paper analyzed hospital billing data from emergency departments due to opioid overdose from 2012 to 2016. Methods: Emergency department records meeting the opioid overdose case definition were aggregated into 6 progressively rural groups using the National Center for Health Statistics (NCHS) urban‐rural county classification from 2013. These data were analyzed to determine significant trends amongst and between the geographic groups. Findings: Generally, the magnitude of opioid overdose morbidity decreased as levels of rurality increased, using annual percentage change as the metric of change. Over the study period, Missouri's most urban counties had significantly higher rates of opioid overdose and saw larger percentage increases in rates compared to more rural areas. Statewide, all rural‐urban classifications experienced increases in heroin overdose morbidity; however, there was extreme variation in the trajectory of those increases. Heroin overdose rates were much higher in urban areas than rural areas. Conversely, rural and urban areas saw relatively similar patterns for non‐heroin opioid overdoses, though overall magnitude of these increases was more modest across all geographic groups. Conclusions: The results from this analysis can help inform prioritization of strategies and resources to implement activities addressing the opioid overdose epidemic. Using a rich hospital discharge database could allow for further analysis of subpopulations to enhance personalization and customization of care. [ABSTRACT FROM AUTHOR]

Purpose: Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) provide primary care in rural areas with a shortage of providers. This paper examines whether racial and ethnic minority composition was related to changes in the supply of RHCs and FQHCs in rural counties from 2000 to 2011. Methods: We conducted a retrospective cohort study of rural counties using the Area Health Resource File 2012‐2013. We examined rural counties defined as non‐Core‐Based Statistical Areas, with complete data on county characteristics for the study period (N = 1,349). Logistic regression analyses estimated associations between percentage of minority residents, and net gains and losses of RHCs and FQHCs, adjusting for total population, percentage of elderly residents, infant mortality rate, poverty rate, and physician, hospital, and clinic supply. Model estimates were used to calculate the predicted probability of outcomes across a range of minority percentage, from the 10th (≤1.6%) to 90th (≥46%) percentile of rural counties. Findings: In high‐minority counties, the predicted probability of a net gain in any type of clinic was 28.6% (95% CI: 21.3‐35.8), versus 46.4% (95% CI: 40.0‐52.8) for low‐minority counties. High‐minority counties were also more likely to experience a net decline in RHCs. Conclusions: During a period of substantial growth in both programs, the percentage of minority residents was negatively associated with gaining new clinics of either type. Policy makers may need to consider targeting rural minority communities for additional primary care workforce support. [ABSTRACT FROM AUTHOR]

Purpose: To document rural young adults’ reasons for emotional reactions to participating in intimate partner violence (IPV) research as well as to hear young adults’ perspectives on how to most effectively conduct comprehensive IPV research in their rural communities. Methods: The data presented in this paper draw from 2 studies (ie, an online survey study and an in‐person or telephone interview study) that included the same 16 US rural counties in New England and Appalachia. Participants, 47% of whom were in both studies, were young (age range 18‐24), white (92%‐94%), heterosexual (89%‐90%), female (62%‐68%), and mostly low to middle income. Findings: Nine percent of participants reported they were upset by the questions due to personal experiences with IPV or for other reasons not related to personal IPV experiences. Forty percent of participants reported they personally benefited from participating in the study, and they provided various reasons for this benefit. Regarding suggestions for conducting IPV research with rural young adults, participants believed that both online recruitment and online data collection methods were the best ways to engage young adults, although many participants suggested that more than 1 modality was ideal, which underscores the need for multimethod approaches when conducting research with rural young adults. Conclusions: These findings are reassuring to those committed to conducting research on sensitive topics with rural populations and also shed light on best practices for conducting this type of research from the voices of rural young adults themselves. [ABSTRACT FROM AUTHOR]

Purpose: To examine the prevalence, patterns, and correlates of prenatal substance use in the rural Appalachian state of West Virginia (WV). Methods: Population‐based cohort (Project WATCH) of all women (N = 34,309) who gave birth between February 2020 and June 2022. A composite substance use variable included 9 categories: "no substance use," "opioids," "cannabis," "sedatives/hypnotics," "stimulants," "opioids and cannabis," "opioids and stimulants," "cannabis and stimulants," and "opioids, cannabis, and stimulants." These data were gathered through self‐report, medical records, and/or positive drug screen at labor and delivery. Findings: 12.4% of women used one or more substances (opioids, cannabis, stimulants, and sedatives/hypnotics) during their current pregnancy. The mean age of women using cannabis was 25.34 (SD = 5.31), stimulants was 28.88 (SD = 5.62), and opioid was 30.19 (SD = 4.78). White women were more likely to use opioids (aOR = 2.19, 95% CI 1.46, 3.28) and less likely to use cannabis (aOR = 0.39, 95% CI 0.34, 0.44) compared to minority racial groups. Women with cannabis use were more likely to live in urban versus rural regions (aOR = 1.47, 95% CI 1.33, 1.62). The odds of using any type of substance(s) were significantly higher in women who smoked (aOR range 4.17‐30.85), had Medicaid (aOR range 1.52‐7.65), and those receiving inadequate prenatal care (aOR range 1.96‐16.83). Conclusions: In this rural Appalachian state, 1 in 8 women used 1 or more substances (opioids, cannabis, stimulants, and/or sedatives/hypnotics) during pregnancy and the type of substance used varied by sociodemographic and health‐related factors. These factors should inform state‐level strategies and initiatives to address the substance use crisis for this population. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate how technology access affected substance use disorder (SUD) treatment prior to COVID‐19 for people who use drugs in rural areas. Methods: The Rural Opioid Initiative (January 2018‐March 2020) was a cross‐sectional study of people with prior 30‐day injection drug or nonprescribed opioid use from rural areas of 10 states. Using multivariable mixed‐effect regression models, we examined associations between participant technology access and SUD treatment. Findings: Of 3,026 participants, 71% used heroin and 76% used methamphetamine. Thirty‐five percent had no cell phone and 10% had no prior 30‐day internet use. Having both a cell phone and the internet was associated with increased days of medication for opioid use disorder (MOUD) use (aIRR 1.29 [95% CI 1.11‐1.52]) and a higher likelihood of SUD counseling in the prior 30 days (aOR 1.28 [95% CI 1.05‐1.57]). Lack of cell phone was associated with decreased days of MOUD (aIRR 0.77 [95% CI 0.66‐0.91]) and a lower likelihood of prior 30‐day SUD counseling (aOR 0.77 [95% CI 0.62‐0.94]). Conclusions: Expanding US rural SUD treatment engagement via telemedicine may require increased cell phone and mobile network access. [ABSTRACT FROM AUTHOR]

Purpose: We tested the feasibility of survivorship care plan (SCP) delivery with/without a lay health educator (LHE) telephone‐delivered information session among rural cancer survivors, and their effects on health‐related self‐efficacy and knowledge of cancer history. Methods: Randomized trial of cancer survivors from 3 rural oncology clinics featuring either SCP alone (control) or SCP plus LHE‐delivered information session (intervention). Participants completed a questionnaire on health‐related self‐efficacy and knowledge of cancer‐specific medical history. Responses were compared to medical records for accuracy. SCPs were then mailed to participants. Approximately 5 months later, participants completed a follow‐up questionnaire. A subset of participants took part in subsequent qualitative interviews about their study experience. Findings: Of 301 survivors approached, 72 (23.9%) were randomized (mean age 66.4 years; 3.1 years from diagnosis; 62.5% female), and 65 (90.3%) completed the study. Global mental and physical health or self‐efficacy scores did not change significantly from baseline to follow‐up for either group. In exploratory analyses, self‐efficacy increased in participants with inadequate/marginal health literacy in the intervention arm (+0.7, 95% CI = 0.1‐1.2; P =.01). Accuracy of knowledge did not improve but was high at baseline (mean 76.0±14.5%). 60.1% and 48.4% of control and intervention participants, respectively, found SCPs definitely/somewhat useful. Qualitative data (n = 20) suggested that SCPs were helpful to patients when primary and oncology care were less integrated. Conclusions: An LHE‐delivered informational session was feasible but had limited benefit to rural cancer survivors versus delivery of SCP alone but may be of benefit to patients with low health literacy or with less integrated care. [ABSTRACT FROM AUTHOR]

Purpose of Study: Medical students who identify as Black, Indigenous, and People of Color (BIPOC) regularly experience mistreatment and discrimination. This study sought to understand these student experiences during rotations in rural and urban underserved community teaching sites. Methods: Self‐identified BIPOC medical students who completed the University of Washington School of Medicine's Rural Underserved Opportunities Program from 2019 through 2021 were invited to participate in a 60‐ to 90‐minute focus group discussion via Zoom. From August to September 2021, 4 focus groups and 1 individual interview were conducted with a total of 12 participants. A current BIPOC medical student facilitated the sessions utilizing questions developed by the research team. Four study team members coded transcripts for key themes related to experiences of microaggressions. Findings: All participants reported having an overall positive experience, but everyone also witnessed and/or experienced at least 1 microaggression. Unlike those in urban placements, participants placed in rural sites expressed anxiety about being in predominantly White communities and experienced feelings of racial and/or ethnic isolation during the rotation. Participants recommended that rural preceptors identify themselves as trusted advocates and the program should prioritize placing BIPOC students at diverse clinical sites. Conclusions: Medical schools must take action to address the mistreatment of BIPOC medical students in the clinical environment. Schools and rural training sites need to consider how to best support students to create an equitable learning environment and recruit more BIPOC physicians to rural practice. [ABSTRACT FROM AUTHOR]

Purpose: To investigate whether rural‐urban differences in quality of care for Medicare Advantage (MA) enrollees vary between females and males. Methods: Data for this study came from the 2019 Healthcare Effectiveness Data and Information Set. Linear regression was used to investigate urban‐rural differences in individual MA enrollee scores on 34 clinical care measures grouped into 7 categories, and how those differences varied by sex (through evaluation of statistical interactions). Findings: Across all 7 categories of measures, scores for rural residents were worse than scores for urban residents. For 4 categories—care for patients with (suspected) chronic obstructive pulmonary disease, avoiding prescription misuse, behavioral health, and diabetes care—the average difference across measures in the category was greater than 3 percentage points. Across all 34 measures, there were 15 statistically significant rural‐by‐sex interactions that exceeded 1 percentage point. In 11 of those cases, the deficit associated with living in a rural area was greater for males than for females. In 3 cases, the deficit associated with living in a rural area was larger for females than for males. In 1 case involving Follow‐up After Hospitalization for Mental Illness, rural residents had an advantage, and it was larger for males than for females. Conclusions: Interventions may help address patient‐ (eg, health literacy and patient activation), provider‐ (eg, workforce recruitment and retention), and structural‐level issues contributing to these disparities, especially for rural males. [ABSTRACT FROM AUTHOR]

Purpose: Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on patient outcomes. Methods: Using 100% Medicare data on postacute HH episodes from 2007 to 2014, we estimated the impact of higher payments on beneficiaries outcomes using difference‐in‐differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010. Findings: Our sample included 5.6 million postacute HH episodes (18% rural). In the preperiod, the 30‐ and 60‐day rehospitalization rates for urban HH episodes were 11.30% and 18.23% compared to 11.38% and 18.39% for rural HH episodes. After 2010, 30‐ and 60‐day rehospitalization rates declined, 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference‐in‐difference estimate was 0.29 percentage points (P =.005) and 0.57 percentage points (P <.001) for 30‐ and 60‐day rehospitalization, respectively. Conclusions: Increasing payments resulted in a statistically significant reduction in rehospitalizations for rural postacute HH episodes. The add‐on payment is set to sunset in 2022 and its impact on access and quality to HH for rural older adults should be reconsidered. [ABSTRACT FROM AUTHOR]

Purpose: Access to paid sick leave is critically important to promoting good health, caregiving, and stopping the spread of disease. In this study, we estimate whether access to paid sick leave among US full‐time workers differs between rural and urban residents. Methods: We used data from the 2020 National Health Interview Survey and included adult respondents between the ages of 18 and 64 who were employed full‐time (n = 12,086). We estimated bivariate differences in access to paid sick leave by rural/urban residence, and then calculated the predicted probability of access to paid sick leave, adjusting for sociodemographic and health characteristics, across different education levels. Findings: We find a nearly 10‐percentage point difference in access to paid sick leave between rural and urban adults (68.1% vs 77.1%, P<.001). The difference in access to paid sick leave between rural and urban residents remained significant even after adjusting for sociodemographic and health characteristics. The fully adjusted predicted probability of paid sick leave for rural full‐time workers was 69.8%, compared with 76.4% for urban full‐time workers (P<.001). We also identified lower levels of paid leave for rural (vs urban) workers within each educational category. Conclusions: Full‐time workers in rural areas have less access to paid sick leave than full‐time workers in urban areas. Without access to paid sick leave, rural and urban residents may go to work while contagious or forego necessary health care. Left to individual employers or localities, rural inequities in access to paid sick leave will likely persist. [ABSTRACT FROM AUTHOR]

Objective To test for significant differences in information technology sophistication (ITS) in US nursing homes (NH) based on location. Methods We administered a primary survey January 2014 to July 2015 to NH in each US state. The survey was cross-sectional and examined 3 dimensions (IT capabilities, extent of IT use, degree of IT integration) among 3 domains (resident care, clinical support, administrative activities) of ITS. ITS was broken down by NH location. Mean responses were compared across 4 NH categories (Metropolitan, Micropolitan, Small Town, and Rural) for all 9 ITS dimensions and domains. Least square means and Tukey's method were used for multiple comparisons. Principal Findings Methods yielded 815/1,799 surveys (45% response rate). In every health care domain (resident care, clinical support, and administrative activities) statistical differences in facility ITS occurred in larger (metropolitan or micropolitan) and smaller (small town or rural) populated areas. Conclusions This study represents the most current national assessment of NH IT since 2004. Historically, NH IT has been used solely for administrative activities and much less for resident care and clinical support. However, results are encouraging as ITS in other domains appears to be greater than previously imagined. [ABSTRACT FROM AUTHOR]

Purpose: Geographic access to cancer care is known to significantly impact utilization and outcomes. Longer travel times have negative impacts for patients requiring highly specialized care, such as for rare cancers, and for those in rural areas. Scant population‐based research informs geographic access to care for rare cancers and whether rurality impacts that access. Methods: Using Medicare data (2014‐2015), we identified prevalent cancers and cancer‐directed surgeries, chemotherapy, and radiation. We classified cancers as rare (incidence <6/100,000/year) or common (incidence ≥6/100,000/year) using previously published thresholds and categorized rurality from ZIP code of beneficiary residence. We estimated travel time between beneficiaries and providers for each service based on ZIP code. Descriptive statistics summarized travel time by rare versus common cancers, service type, and rurality. Findings: We included 1,169,761 Medicare beneficiaries (21.9% in nonmetropolitan areas), 87,399; 7.5% had rare cancers, with 9,133,003 cancer‐directed services. Travel times for cancer services ranged from approximately 29 minutes (25th percentile) to 68 minutes (75th percentile). Travel times were similar for rare and common cancers overall (median: 45 vs 43 minutes) but differed by service type; 13.4% of surgeries were >2 hours away for rare cancers, compared to 8.3% for common cancers. Increasing rurality disproportionately increased travel time to surgical care for rare compared to common cancers. Conclusions: Travel times to cancer services are longest for surgery, especially among rural residents, yet not markedly longer overall between rare versus common cancers. Understanding geographic access to cancer care for patients with rare cancers is important to delivering specialized care. [ABSTRACT FROM AUTHOR]

Purpose: Rural disparities exist in access to multidisciplinary pain care with higher rates of opioid prescribing in rural regions. Among Veterans, who have prevalent rates of chronic pain, women often evidence complex presentations, multiple comorbidities, and dissatisfaction with care. This study investigates the impact of rurality on pain care for women specifically, and whether this varies from the impact of rurality for men. Methods: A cohort of Veterans with chronic pain in 2018 was built utilizing VA administrative data. Variables of interest included: demographic, comorbidities, medications, and health care utilization for chronic pain. Findings: The cohort included 2,261,030 Veterans; 11% (n = 248,977) were women. Significantly fewer women (7%) compared to men (10.7%) received long‐term opioids (adjusted OR = 0.77, 95% CI: 0.75‐0.78). Men, relative to women, were also more likely to receive gabapentinoids and nonsteroidal ant‐inflammatory drugs, whereas women, relative to men, were more likely to receive muscle relaxants and duloxetine. Women were more likely to receive most psychiatric medications. Rural women received more primary care visits compared to urban women (adjusted OR = 1.19, 95% CI: 1.15‐1.22), but fewer women's clinic visits (a subset of primary care visits: adjusted OR = 0.69, 95% CI:0.67‐0.71) and fewer pain specialty care visits (physical therapy, pain clinic, and mental health visits with pain codes). Rural effects did not vary substantially between women and men. Conclusions: Rural‐dwelling Veterans received more pain and psychiatric medications compared to urban Veterans and fewer specialty care visits. Rural Veterans may benefit from increased access to specialty chronic pain care. [ABSTRACT FROM AUTHOR]

Purpose: To investigate telehealth use for contraceptive service provision among rural and urban federally qualified health centers (FQHCs) in Alabama (AL) and South Carolina (SC) during the initial months of the COVID‐19 pandemic. Methods: This is a mixed‐methods study using data from the FQHC Contraceptive Care Survey and key informant interviews with FQHC staff in AL and SC conducted in 2020. Differences between rural and urban clinics in telehealth use for contraceptive service provision were assessed with a chi‐square test of independence. Interviews were audio recorded, transcribed, and coded to identify facilitators and barriers to telehealth. Findings: Telehealth for contraceptive care increased during the early months of the pandemic relative to prepandemic. Fewer rural clinics than urban clinics provided telehealth for contraceptive counseling (16.3% vs 50.6%) (P =.0002), emergency contraception (0.0% vs 16.1%) (P =.004), and sexually transmitted infection care (16.3% vs 34.6%) (P =.031). Key facilitators of telehealth were reimbursement policy, electronic infrastructure and technology, and funding for technology. Barriers included challenges with funding for telehealth, limited electronic infrastructure, and reduced staffing capacity. Conclusions: Differences in telehealth service provision for contraceptive care between rural and urban FQHCs highlight the need for supportive strategies to increase access to care for low‐income rural populations, particularly in AL and SC. It is essential for public and private entities to support the implementation and continuation of telehealth among rural clinics, particularly, investing in widespread and clinic‐level electronic infrastructure and technology for telehealth, such as broadband and electronic health record systems compatible with telehealth technology. [ABSTRACT FROM AUTHOR]

Purpose: To examine associations between perceived ease of syringe access, syringe sources, injection behaviors, and law enforcement (LE) interactions among people who inject drugs (PWID) in rural Appalachian North Carolina (NC). Methods: Using respondent‐driven sampling, a diverse sample of 309 self‐reported PWID were recruited from rural Appalachian NC. Data were collected via audio computer‐assisted self‐interview technology from February 2019 through March 2020. Respondents reported demographics, sources of syringes, LE interactions, and injection behaviors. Univariate, bivariate, and linear regression analyses were performed. Findings: Respondents most often obtained syringes from pharmacies and syringe service programs (SSPs). Twenty‐one percent disagreed that it was easy to obtain sterile syringes, with 28% reporting low or no access to an SSP. PWID who reported longer physical distances to an SSP had greater difficulty accessing syringes (P<.001). PWID who reported greater ease of access to syringes reported engaging in receptive syringe sharing less often (P<.01). PWID who were stopped and searched by LE more often reported injecting drugs somebody else prepared with nonsterile supplies more often (P<.01). Participants shared used injection supplies more than twice as often than they shared used syringes. Conclusions: These results underscore the importance of SSPs to mitigate the spread of human immunodeficiency virus and viral hepatitis in rural areas. Supporting mobile SSP services in rural areas could increase access to sterile syringes and injection supplies. SSPs should educate PWID about the importance of not sharing injection supplies. Pharmacies could increase syringe access in areas where SSPs do not operate. [ABSTRACT FROM AUTHOR]

Purpose: With surging opioid‐involved overdoses, maintaining access to opioid use disorder (OUD) treatment is critical during the COVID‐19 pandemic. We examined changes in transmucosal buprenorphine prescribing for OUD treatment in Kentucky after the national COVID‐19 emergency declaration, with a focus on rural‐urban differences. Methods: Using 2019‐2020 prescription monitoring data, we performed segmented regression analysis for an interrupted time series design to evaluate changes in weekly rates (per 100,000 residents) of dispensed prescriptions, unique individuals with dispensed prescriptions, and average days' supply for dispensed prescriptions of transmucosal buprenorphine. Findings: The weekly rates of dispensed prescriptions and unique individuals with dispensed prescriptions were higher for rural residents than urban residents. After the national COVID‐19 emergency declaration, rural and urban residents experienced similar immediate drops in the rate of dispensed prescriptions (rural –33.4; urban –24.3) and unique patients with dispensed prescriptions (rural –25.0; urban –17.1), followed by similar sustained increases. Both measures surpassed the prepandemic levels in mid‐June 2020. Patients residing in urban areas received averagely longer prescriptions at baseline (urban: 11.0 days; rural: 10.5 days). The average weekly days' supply increased in the week after the national emergency declaration, but the estimated increase was higher (P =.004) for urban (0.8 days) versus rural (0.5 days) residents. Conclusions: Transmucosal buprenorphine utilization increased during the COVID‐19 pandemic after experiencing interruption during the initial weeks of the pandemic. Future studies should evaluate the contribution of the relaxed telemedicine buprenorphine prescribing regulations during the COVID‐19 national emergency on initiation and maintenance of buprenorphine treatment. [ABSTRACT FROM AUTHOR]

Background: Research is needed that identifies environmental resource disparities and applies multiple rural definitions. Therefore, this study aims to examine urban‐rural differences in food and physical activity (PA) environment resource availability by applying several commonly used rural definitions. We also examine differences in resource availability within urban‐rural categories that are typically aggregated. Methods: Six food environment variables (access to grocery/superstores, farmers' markets, fast food, full‐service restaurants, convenience stores, and breastfeeding‐friendly facilities) and 4 PA environment variables (access to exercise opportunities and schools, walkability, and violent crimes) were included in the childhood obesogenic environment index (COEI). Total COEI, PA environment, and food environment index scores were generated by calculating the average percentile for related variables. US Department of Agriculture Urban Influence Codes, Office of Management and Budget codes, Rural‐Urban Continuum Codes, Census Bureau Population Estimates for percent rural, and Rural Urban Commuting Area Codes were used. One‐way ANOVA was used to detect urban‐rural differences. Results: The greatest urban‐rural disparities in COEI (F=310.2, P<.0001) and PA environment (F=562.5, P<.0001) were seen using RUCC codes. For food environments, the greatest urban‐rural disparities were seen using Census Bureau percent rural categories (food: F=24.9, P<.0001). Comparing remote rural categories, differences were seen for food environments (F=3.1, P=.0270) and PA environments (F=10.2, P<.0001). Comparing metro‐adjacent rural categories, differences were seen for PA environment (F=4.7, P=.0090). Conclusion: Findings inform future research on urban and rural environments by outlining major differences between urban‐rural classifications in identifying disparities in access to health‐promoting resources. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate disparities in urban‐rural immunization rates among pregnant women by indicators of access to health care. Methods: We analyzed Phase 8 (2016‐2018) Pregnant Risk Assessment Monitoring System data for 82,603 respondents who recently gave birth to a live infant. Uptake of influenza (33 states) or Tdap (19 states) vaccines was compared for rural versus urban areas of participating states. We compared the prevalence of immunization for rural versus urban areas by indicators of health care access using average marginal predictive values from multivariable regression models. Findings: Although nearly half (48.2%) of pregnant women in rural areas relied on Medicaid to fund prenatal care, rural‐residing women were less likely to live in a state offering full coverage under Medicaid to pregnant women than urban‐residing women (93.9% vs 98.0%, respectively). Among states with Medicaid programs not offering full access for pregnant women, influenza immunization coverage was 12% lower (aPR 0.88; 95% CI 0.82, 0.94) and Tdap immunization coverage was 20% lower (aPR 0.80; 95% CI 0.68, 0.95) for rural versus urban areas. Uninsured women in rural areas were less likely to receive influenza or Tdap vaccine compared to uninsured women in urban areas (aPR 0.65; 95% CI 0.50, 0.85 and aPR 0.73; 95% CI 0.57, 0.95, respectively). Conclusions: Pregnant women residing in rural areas more commonly rely on Medicaid to financially support prenatal care but are less likely to have expanded or full access to Medicaid coverage, potentially contributing to disparities vaccine uptake during pregnancy and increased rates of vaccine‐preventable disease. [ABSTRACT FROM AUTHOR]

Purpose: Overdose is a leading cause of death among people who use drugs (PWUDs), but policies to reduce fatal overdose have had mixed results. Summaries of naloxone access and Good Samaritan Laws (GSLs) in prior studies provide limited information about local context. Witnessing overdoses may also be an important consideration in providing services to PWUDs, as it contributes to post traumatic stress disorder (PTSD) symptoms, which complicate substance use disorder treatment. Methods: We aim to estimate the prevalence and correlates of witnessing and responding to an overdose, while exploring overdose context among rural PWUD. The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) mixed‐methods study characterized substance use and risk behaviors in 11 rural Massachusetts, Vermont, and New Hampshire counties between 2018 and 2019. PWUD completed surveys (n = 589) and in‐depth interviews (n = 22). Findings: Among the survey participants, 84% had ever witnessed an overdose, which was associated with probable PTSD symptoms. Overall, 51% had ever called 911 for an overdose, though some experienced criminal legal system consequences despite GSL. Although naloxone access varied, 43% had ever used naloxone to reverse an overdose. Conclusions: PWUD in Northern New England commonly witnessed an overdose, which they experienced as traumatic. Participants were willing to respond to overdoses, but faced barriers to effective overdose response, including limited naloxone access and criminal legal system consequences. Equipping PWUDs with effective overdose response tools (education and naloxone) and enacting policies that further protect PWUDs from criminal legal system consequences could reduce overdose mortality. [ABSTRACT FROM AUTHOR]

Purpose: We conducted a 12‐month pilot study of 2 complementary strategies for improving rural cancer survivorship outcomes: (1) Project ECHO, a telementoring model to increase knowledge and skills about cancer survivorship among multidisciplinary health care provider teams in rural areas and (2) patient navigation (PN) services to connect rural cancer survivors with resources for enhancing health and wellness. Methods: We recruited 4 CDC‐funded National Comprehensive Cancer Control Program sites to implement Project ECHO and PN interventions for a defined rural population in each of their jurisdictions. Sites received ongoing technical assistance and a stipend to support implementation. We conducted a mixed‐methods evaluation consisting of quantitative performance monitoring data and qualitative interviews with site staff to assess implementation. Findings: Site teams delivered 21 cancer survivorship ECHO sessions to rural providers resulting in 329 participant encounters. Almost all (93%) ECHO participants reported enhanced knowledge of cancer survivorship issues, and 80% reported intent to apply learnings to their practices. Site teams engaged 16 patient navigators who navigated 164 cancer survivors during the study period. Successful implementation required strong partnerships, clear avenues for recruitment of rural providers and cancer survivors, and activities tailored to local needs. Fostering ongoing relationships among sites through community of practice calls also enhanced implementation. Conclusions: Sites successfully implemented a novel approach for enhancing care for cancer survivors in rural communities. Pairing Project ECHO to address structural barriers and PN to address individual factors affecting survivorship may help bridge the health equity gap experienced by cancer survivors in rural communities. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to assess perceptions, health behaviors, and disruptions related to the COVID‐19 pandemic in a largely rural, Midwestern state, and to examine differences between rural and urban respondents. Methods: A questionnaire was mailed August 2020 to a sample of 10,009 registered voters in Iowa ages 18‐100 years, with oversampling from 6 select rural counties. Previously validated and tested items assessed COVID‐19 precautions, health care disruptions, emotional reactions, health behavior changes, telehealth and experiences with the internet, and demographic characteristics. Findings: There were 4,048 respondents (40% response rate); 65% were rural and 35% were urban residents. The average age of respondents was 58.3 years and 45% of respondents identified as female. Rural respondents reported less concern about COVID‐19 in their community (29% vs 40%, P<.001) and lower perceived importance of social distancing (51% vs 64%, P<.001). Urban respondents more often reported experiencing disruption to daily living, stronger negative emotional reactions, and displayed more pronounced behavior change compared to their rural counterparts. For example, urban respondents reported more pandemic‐related job losses (6% vs 4%, P =.05), disruptions to daily activities (48% vs 35%, P<.001), and use of telehealth services during the pandemic (24% vs 16%, P<.001). Conclusions: The majority of respondents reported disruptions to normal activities, medical appointment cancellations, and emotional distress during the first 6 months of the pandemic. The impact of the pandemic on urban residents appeared to be greater than for rural respondents. Timing of pandemic spread and varying beliefs are potential explanations. [ABSTRACT FROM AUTHOR]

Purpose: How care delivery influences urban‐rural disparities in cancer outcomes is unclear. We sought to understand community oncologists' practice settings to inform cancer care delivery interventions. Methods: We conducted secondary analysis of a national dataset of providers billing Medicare from June 1, 2019 to May 31, 2020 in 13 states in the central United States. We used Kruskal‐Wallis rank and Fisher's exact tests to compare physician characteristics and practice settings among rural and urban community oncologists. Findings: We identified 1,963 oncologists practicing in 1,492 community locations; 67.5% practiced in exclusively urban locations, 11.3% in exclusively rural locations, and 21.1% in both rural and urban locations. Rural‐only, urban‐only, and urban‐rural spanning oncologists practice in an average of 1.6, 2.4, and 5.1 different locations, respectively. A higher proportion of rural community sites were solo practices (11.7% vs 4.0%, P<.001) or single specialty practices (16.4% vs 9.4%, P<.001); and had less diversity in training environments (86.5% vs 67.8% with <2 medical schools represented, P<.001) than urban community sites. Rural multispecialty group sites were less likely to include other cancer specialists. Conclusions: We identified 2 potentially distinct styles of care delivery in rural communities, which may require distinct interventions: (1) innovation‐isolated rural oncologists, who are more likely to be solo providers, provide care at few locations, and practice with doctors with similar training experiences; and (2) urban‐rural spanning oncologists who provide care at a high number of locations and have potential to spread innovation, but may face high complexity and limited opportunity for care standardization. [ABSTRACT FROM AUTHOR]

Purpose: Research examining psychological well‐being associated with COVID‐19 in rural/regional Australia is limited. This study aimed to assess the extent of psychological distress, fear of COVID‐19, and coping strategies among the attendees in COVID‐19 screening clinics at 2 rural Victorian settings. Methods: A cross‐sectional study was conducted during July 2020 to February 2021 inclusive. Participants were invited to fill in an online questionnaire. Kessler Psychological Distress Scale (K‐10), Fear of COVID‐19 Scale, and Brief Resilient Coping Scale were used to assess psychological distress, fear of COVID‐19, and coping, respectively. Findings: Among 702 total participants, 69% were females and mean age (±SD) was 49 (±15.8) years. One in 5 participants (156, 22%) experienced high to very high psychological distress, 1 in 10 (72, 10%) experienced high fear, and more than half (397, 57%) had medium to high resilient coping. Participants with mental health issues had higher distress (AOR 10.4, 95% CI: 6.25‐17.2) and fear (2.56, 1.41‐4.66). Higher distress was also associated with having comorbidities, increased smoking (5.71, 1.04‐31.4), and alcohol drinking (2.03, 1.21‐3.40). Higher fear was associated with negative financial impact, drinking alcohol (2.15, 1.06‐4.37), and increased alcohol drinking. Medium to high resilient coping was associated with being ≥60 years old (1.84, 1.04‐3.24) and completing Bachelor and above levels of education. Conclusion: People who had pre‐existing mental health issues, comorbidities, smoked, and consumed alcohol were identified as high‐risk groups for poorer psychological well‐being in rural/regional Victoria. Specific interventions to support the mental well‐being of these vulnerable populations, along with engaging health care providers, should be considered. [ABSTRACT FROM AUTHOR]

Purpose: To test the efficacy of a theory‐based behavioral intervention delivered via telephone versus clinic‐based counseling to improve HIV outcomes and reduce alcohol consumption for people at‐risk for treatment failure in a rural setting. Methods: Patients receiving HIV care (N = 240) were randomized using a computer‐generated scheme to one of three conditions: (a) telephone behavioral health counseling, (b) clinic‐based behavioral health counseling, or (c) attention control nutrition education. Behavioral counseling was delivered by either a community nurse or a paraprofessional patient navigator, with differences examined. Participants were followed for 12 months to assess medication adherence using unannounced pill counts and alcohol use measured by electronic daily text message assessments, and 18 months for HIV viral load and retention in care extracted from medical records. Findings: There was evidence for telephone and office‐based counseling demonstrating greater medication adherence than the control condition but only in the short term. Clinic‐based behavioral counseling significantly reduced alcohol use to a greater degree than telephone counseling and the control condition. There were no other differences between conditions. There were also no discernable differences between counseling delivered by the community nurse and the patient navigator. Conclusions: Telephone and clinic‐based counseling demonstrated improved medication adherence in the short term, while clinic‐based counseling demonstrated reductions in alcohol use. The modest outcomes suggest that intensive intervention strategies are needed for patients that clinicians identify as at‐risk for treatment discontinuation and treatment failure. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to develop and provide initial evidence of the validity and reliability of the Rural Practice Awareness and Skills Scale (RPASS). Methods: A pool of 63 items was reviewed by an expert panel, subjected to 2 additional face validity checks, and reduced to 39 items. The scale was then completed by 333 participants, and an exploratory factor analysis and confirmatory factor analysis were conducted. Findings: Results revealed a 3‐factor, 20‐item scale with evidence of reliability and convergent validity. Conclusions: RPASS has utility for advancing research to support recruitment and retention of rural health providers and ultimately enhance rural health care delivery. [ABSTRACT FROM AUTHOR]

Purpose: As the number of women veterans receiving care from the Veterans Health Administration (VHA) continues to increase, so does the need to access gender‐specific preventive health care services through the VHA. In rural areas, women veterans are the numeric minority, so many preventive screenings are performed outside of the VA by community providers. As the numbers of veterans utilizing both VHA and non‐VHA providers for their preventive care continue to increase, so does the need to coordinate this care. This research examines the role of the Women Veterans' Care Coordinator (WVCC) at rural facilities and their perceptions of coordinating preventive care. Methods: Between March and July 2019, semi‐structured telephone interviews were conducted with WVCCs at 26 rural VA facilities. Each interview was digitally recorded and transcribed verbatim. Transcripts were loaded into Atlas.ti for further analysis. Once the codes were refined, the investigators coded the 26 interviews independently and conferred to achieve consensus on the underlying themes. Findings: Five themes arose from the WVCC interviews: (1) Rural women veterans have varying needs of coordination; (2) Fragmented communication between the VA and non‐VA care settings hinders effective coordination; (3) Difficulties in prioritizing rural care coordination; (4) Care coordination impacts patient care; and (5) WVCC recommendations to improve rural care coordination. Conclusions: The recent addition of WVCCs to rural facilities has expanded the VA's reach to veterans living in the most rural areas. As a result, many of these women are now receiving timely, quality, and coordinated health care. [ABSTRACT FROM AUTHOR]

Purpose: We previously described the magnitude of rural‐urban differences in the prevalence of stroke risk factors and stroke mortality. In this report, we sought to extend the understanding of rural‐urban differences in the prevalence of stroke risk factors by using an enhanced definition of rural‐urban status and assessing the impact of neighborhood socioeconomic status (nSES) on risk factor differences. Methods: This analysis included 28,242 participants without a history of stroke from the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Participants were categorized into the 6‐level ordinal National Center for Health Statistics Urban‐Rural Classification Scheme. The prevalence of stroke risk factors (hypertension, diabetes, smoking, atrial fibrillation, left ventricular hypertrophy, and heart disease) was assessed across the rural‐urban scale with adjustment for demographic characteristics and further adjustment for nSES score. Findings: Hypertension, diabetes, and heart disease were more prevalent in rural than urban regions. Higher odds were observed for these risk factors in the most rural compared to the most urban areas (odds ratios [95% CI]: 1.25 [1.11‐1.42] for hypertension, 1.15 [0.99‐1.33] for diabetes, and 1.19 [1.02‐1.39] for heart disease). Adjustment for nSES score partially attenuated the odds of hypertension and heart disease with rurality, completely attenuated the odds of diabetes, and unmasked an association of current smoking. Conclusions: Some of the higher stroke mortality in rural areas may be due to the higher burden of stroke risk factors in rural areas. Lower nSES contributed most notably to rural‐urban differences for diabetes and smoking. [ABSTRACT FROM AUTHOR]

Purpose: To contrast trends in rural and urban pediatric home health care use among Medicaid enrollees. Methods: Medicaid administrative claims data were used to assess differences in home health care use for child members in a large pediatric accountable care organization (ACO) in Ohio. Descriptive statistics assessed rural and urban differences in health care use over a 10‐year period between 2010 and 2019. Findings: Pediatric home health care use increased markedly in the low‐income (CFC) and disabled (ABD) Medicaid categories. Over the past 10 years, CFC‐enrolled children from urban communities have seen more home health visits, fewer emergency department (ED) visits, and more well child visits compared to rural CFC‐enrolled children. Children enrolled due to disabilities in urban communities have also seen more home health visit use but fewer preventive care visits than their rural counterparts. Conclusions: Within a pediatric ACO, rural home health care use has remained relatively stagnant over a 10‐year period, a stark contrast to increases in home health care use among comparable urban populations. There are likely multiple explanations for these differences, including overuse in urban communities, lack of access in rural communities, and changes to home health reimbursement. More can be done to improve rural home health access. Such improvement will likely necessitate large‐scale changes to home health care delivery, workforce, and financing. Improvements should be evaluated for return‐on‐investment not only in terms of direct costs, that is, reduced inpatient or ED costs, but also in terms of patient and family quality‐of‐life or key indicators of child well‐being such as educational attainment. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the current study was to evaluate associations between geographic rurality and tobacco use patterns among adolescents. Methods: High school students (N = 566) from north‐central Appalachia reported on their lifetime and/or current use of cigarettes, electronic cigarettes (ECIGs), cigars, and smokeless tobacco. Geographic rurality was measured via the Isolation scale, whereby residential ZIP Codes determined the degree to which respondents have access to health‐related resources. Latent class analysis (LCA) was used to identify discrete classes of adolescent tobacco users based on their use of tobacco products. Then, associations between participants' geographic rurality and class membership were evaluated using a series of multinomial logistic regressions. Findings: LCA classified participants as Nonusers, Current ECIG Users, Cigarette/ECIG Experimenters, and Polytobacco Users. Individuals with higher Isolation scores were more likely to be Polytobacco Users and Cigarette/ECIG Experimenters than Nonusers, and were more likely to be Polytobacco Users than Current ECIG Users. Conclusions: The continuous Isolation scale used in the present study predicted polytobacco use patterns among adolescents in a manner that is consistent with, while simultaneously expanding upon, prior work. Tobacco control practices and policies should be viewed through a lens that considers the unique needs of geographically isolated areas. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to conduct a psychometric evaluation of a new 35‐item survey developed in the United States to measure rural identity. Methods: Factor structure, reliability, convergent validity, and incremental validity of the Rural Identity Scale (RIS) were examined using two datasets. Study 1 examined RIS psychometric properties using survey data collected from substance use treatment counselors in a southeastern state (n = 145), while Study 2 used data collected from women incarcerated in rural jails (n = 400). Findings: A one‐factor structure containing 15 items was identified in the RIS, with acceptable internal reliability (α =.72–.83). In Study 1, participants from rural counties had significantly higher RIS scores than their urban counterparts. In both studies, convergent validity was evaluated and the RIS scores were significantly associated with other measures relevant to identity and rurality at the bivariate level. Incremental validity was supported in multivariable models as the RIS scores were significantly and uniquely associated with primary rural place variables in each sample. Conclusions: This study is an initial step toward a reliable, valid scale measuring rural identity. RIS may be especially beneficial to health research as a methodological tool that can contextualize health behaviors among rural populations and highlight potential interventions to promote health equity. [ABSTRACT FROM AUTHOR]

Purpose: Distances to obstetric care providers are a persistent concern, especially for rural pregnant adolescents. Births to adolescents are disproportionately affected by adverse birth outcomes (ABOs), yet little is known regarding how driving distances may impact ABOs. This study examines the association between driving distances to obstetric providers and ABOs among adolescent mothers in South Carolina. Methods: This retrospective cross‐sectional study derived ZIP Code‐level birth statistics from mothers aged 10–19 in South Carolina using 2013–2017 statewide birth certificate data. ABOs included preterm birth and/or low birthweight. Provider distance was calculated between an obstetric provider's ZIP Code tabulated area (ZCTA) centroid and a maternal resident's ZCTA centroid. Descriptive statistics and weighted generalized linear regression were conducted. Results: Mean provider distances to obstetric providers were similar between urban (11.76 miles) and rural adolescent mothers (12.04 miles). An increase in provider distance, on average, was associated with a decrease in ABO rates (–0.79, p=.0038); however, rural–urban differences were found. Living in a rural ZCTA was associated with a decrease in ABOs (4.94%, p =.0043). Urban ZCTAs showed a U‐shaped association with provider distance, with ABO rates decreasing until approximately 17 miles away from a provider and then increasing. Conclusion: Rural adolescent mothers with greater distance to providers had lower ABO rates, while, in urban ZCTAs, provider distance over 17 miles was associated with higher ABO rates. Understanding what mitigates the effects of driving distance on ABOs in rural South Carolina would help inform future policy planning in underserved communities. [ABSTRACT FROM AUTHOR]

Purpose: This study compared differences in sociodemographic characteristics, personal risk perception of lung cancer, lung cancer worry, and synergistic risk perception among rural Appalachia residents who completed home radon testing with those who did not, after receiving a free long‐term test kit at a rural primary care clinic. The study also examined the association between the Teachable Moment Model constructs and home radon testing. Methods: The study was an exploratory correlational design with a convenience sample of (N = 58) adult participants recruited from 2 rural primary care clinics in Appalachia Kentucky. Participants completed a brief survey and were given a free long‐term home radon test kit. Multiple logistic regression was used to determine characteristics associated with home radon testing. Findings: Twenty‐eight participants (48%) completed home radon testing. There were no differences in personal risk perception of lung cancer, lung cancer worry, or synergistic risk perception between those who completed home radon testing and those who did not. Age was the only significant factor associated with completion of radon testing (B = 0.077, P =.005). For every 5‐year increase in age, participants were 47% more likely to test their home for radon. Conclusion: Providing free home radon test kits in the primary care setting shows promise in prompting radon testing in rural Appalachia. As radon‐induced lung cancer risk increases with exposure over time, health care providers in rural Appalachia need to encourage patients of all ages to test their home for radon, especially those who smoke or report smoking in the home. [ABSTRACT FROM AUTHOR]

Purpose: Understanding knowledge of and attitudes toward medication‐assisted treatment (MAT) for opioid use disorder (OUD) is important to changing the conversation about this devastating public health problem. While several studies report clinician knowledge and attitudes and training, less is known about community member perspectives. As part of the Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado study (IT MATTTRs), this study describes the implementation of community‐based interventions developed by rural community members and researchers to increase awareness and promote positive attitudes toward MAT for OUD and explores changes in community members' OUD and MAT knowledge and beliefs. Methods: Using the Boot Camp Translation process, the High Plains Research Network and Colorado Research Network MAT Advisory Councils developed multicomponent interventions on MAT for OUD. Baseline and postintervention surveys were administered using venue‐based sampling of community members in rural communities. Findings: Surveys were completed by 789 community members at baseline and 798 at postintervention. Nearly half (49%) reported exposure to at least 1 intervention product. Greater exposure to intervention materials was associated with beliefs that using opioids to get high in rural communities is a problem (P <.0001), that opioid addiction is a chronic disease (P =.0032), and that OUD can be treated locally (P =.0003). Conclusions: Partnering with local community members resulted in the successful development and implementation of community‐based interventions, exposure to which was associated with OUD knowledge and beliefs. Locally created interventions should be included in comprehensive approaches to stem the OUD epidemic. [ABSTRACT FROM AUTHOR]

Purpose: We examined the impact on geographic distribution of medications to treat opioid use disorder (MOUD) in Oregon after the Comprehensive Addiction and Recovery Act (CARA) was implemented in February 2017 to include nurse practitioner (NP) prescribers. Methods: We conducted interrupted time series analysis with linear regression on prescriptions dispensed for buprenorphine used for MOUD in the Oregon Prescription Drug Monitoring Database written by physician (MD/DO) and NP prescribers January 1, 2016, to December 31, 2018. We analyzed total prescriptions by prescriber type and pharmacy ZIP Code using STATA 16.1. Findings: From January 1, 2016, to December 31, 2018, 420,765 eligible prescriptions were written by waivered MD/DO and/or NP prescribers. Prior to CARA, buprenorphine use was increasing steadily at 140 prescriptions per month (95% CI: 78‐201; P <.01). Following CARA, dispensing increased by 88 prescriptions per month (95% CI: 23‐152; P =.01). The absolute number increased in rural areas immediately after CARA implementation (368 prescriptions; 95% CI: 124‐613; P <.01). NP contribution to total buprenorphine prescribing increased significantly in both urban and rural areas (0.44% per month [95% CI: 0.30%‐0.57%; P <.01] and 0.74% per month [95% CI: 0.62%‐0.85%; P <.01]). The contribution of NPs had a particularly large impact for very rural (frontier) areas, where NPs provided 36% of all buprenorphine prescriptions by the end of 2018. Conclusion: Changes in federal law regarding MOUD had a positive impact on both supply and geographic distribution in Oregon, particularly in frontier areas comprising 10 of 36 counties (27%). [ABSTRACT FROM AUTHOR]

Purpose: Rural residents are more likely to be obese than urban residents. Research on how people navigate their local food environments through food acquisition behaviors, such as food shopping and restaurant use, in different types of communities may help to create a deeper understanding of the multilevel determinants of obesity. Methods: Data are from a national sample of US adults ages 18‐75. Respondents were recruited from an online survey panel in 2015 and asked about food shopping, restaurant use, diet and weight (N = 3,883). Comparisons were made by level of rurality as assessed by Rural‐Urban Continuum Codes (RUCC) and self‐reported rurality of the area around their home. Findings: Food acquisition behaviors varied minimally by RUCC‐defined level of rurality, with the exceptions of type and distance to primary food store. Rural residents drove further and were more likely to shop at small grocery stores and supercenters than were residents of semiurban or urban counties. In contrast, all of the food acquisition behaviors varied by self‐reported rurality of residential areas. Respondents living in rural areas shopped for groceries less frequently, drove further, more commonly shopped at small grocery stores and supercenters, and used restaurants less frequently. In multivariable analyses, rural, small town, and suburban areas were each significantly associated with BMI and fruit and vegetable intake, but not percent energy from fat. Conclusion: Findings show that self‐reported rurality of residential area is associated with food acquisition behaviors and may partly explain rural‐urban differences in obesity and diet quality. [ABSTRACT FROM AUTHOR]

Purpose: Rural residents may be at higher risk for loneliness than urban residents due to factors such as social isolation, poorer health, and socioeconomic disadvantage. To date, there have been few studies examining rural‐urban differences in loneliness among adults in the United States. We examined differences in loneliness across the rural‐urban continuum among adult residents living in Washington State. Methods: Stratified random sampling was used to select 2,575 adults from small rural, large rural, suburban, and urban areas who were invited to complete a survey on factors affecting health. Data were obtained from 616 adults (278 from small rural, 100 from large rural, 98 from suburban, and 140 from urban areas) from June 2018 through October 2019. Loneliness was measured using the UCLA Loneliness Scale (3rd version). Multivariable linear and logistic regressions were used to examine geographic differences in loneliness (measured continuously and dichotomously). Findings: Mean unadjusted loneliness scores were lower in suburban compared to urban areas (35.06 vs 38.57, P =.03). The prevalence of loneliness was 50.7%, 59.0%, 40.8%, and 54.3% in small rural, large rural, suburban, and urban areas, respectively. Suburban living was associated with lower odds for being lonely compared to urban living (unadjusted OR = 0.58; 95% CI = 0.34‐0.98), but this association was not statistically significant in the adjusted model (OR = 0.63; 95% CI = 0.33‐1.19). Conclusion: Loneliness is a prevalent health issue across the rural‐urban continuum among Washington State adults. [ABSTRACT FROM AUTHOR]

Purpose: Nonmetropolitan communities are faced with health care professional shortages and prior reports suggest that general surgeons are no exception. The purpose of this brief is to evaluate the age difference and distribution of rural versus urban general surgeons to highlight the growing need to recruit medical students and residents for rural practice. Methods: A secondary data analysis of residency graduated general surgeon demographics at the county level was performed using data from the Area Health Resource File. General surgeon demographic data were compared between nonmetropolitan and metropolitan areas. Findings: The number of general surgeons practicing in rural communities is decreasing by a rate of approximately 0.5%‐1.0% annually. Moreover, the entry of younger (<35 years of age) general surgeons into rural counties (8.7%) was less than urban regions (12.1%). Rural general surgeons tended to be older than their urban peers, and on average, rural general surgeon age exhibits a negative skewed, platykurtic distribution. Conclusions: Immediate action must be taken to generate more surgeons for rural practice. A failure to increase recruitment and retention of rural surgeons may have severe consequences on the health status of rural communities. [ABSTRACT FROM AUTHOR]

Purpose: Scope of practice of family physicians (FPs) has been decreasing overall. Our objective was to determine if the distribution of declining scope occurs across urban and rural settings. Methods: We used secondary data from practicing FPs collected on the American Board of Family Medicine examination registration demographic questionnaire from 2014 to 2016 on scope of practice merged with county‐level data from the Area Health Resources File. Rurality was assigned using 4 population‐based groupings from the Rural Urban Continuum Codes. Outcome measures were scope of practice score (0‐30, higher score reflecting broader scope) and provision of specific types of care/procedures. Bivariate statistics assessed changes in scope of practice over time. Adjusted regression models tested associations between time, physician, practice, and county characteristics with scope of practice score. Findings: Our sample was 27,343 practicing FPs. Overall, the scope score decreased from 15.5 to 15.0 (P value <.05) but was significant only for urban settings. Regression analysis found that scope decreased each year (β = –0.15), broader scope for rural FPs, and no interaction between year and rural. Conclusions: The decrease in FP scope of practice is largely an urban phenomenon. FPs in rural areas have a broad scope of practice, which may ensure access to care in rural areas that rely on FPs to provide a large portion of health care services. However, county characteristics like persistent poverty and the presence of nurse practitioners, physician assistants, and other physicians were associated with changes in scope that may modify the gains associated with rurality. [ABSTRACT FROM AUTHOR]