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Objective: The aim of the study is to examine whether inpatient rehabilitation facility patients' risk-adjusted functional outcomes varied with the following five social drivers of health: Medicare-Medicaid dual eligibility status, race and ethnicity, rural residence, socioeconomic status, and living alone. Design: This cohort study examined unadjusted and adjusted mobility and self-care change scores during inpatient rehabilitation facility stays for 428,710 Medicare patients with and without social drivers of health. Regression models isolated the mean marginal effect of each of the five social factors on mobility and self-care change scores after adjusting for covariates. Results: Patients with full dual status had slightly lower risk-adjusted mobility and self-care improvement (−4.5% and −3.3%, respectively) compared with patients without dual status. Patients who identified as Black, Asian, and Native Hawaiian had self-care marginal effects that were slightly lower (−4.8%, −4.1%, and −3.7%, respectively) than patients who were White. Patients living in lower socioeconomic status neighborhoods and patients who lived alone had slightly higher mobility and self-care improvement scores. Risk-adjusted marginal differences in improvement scores for patients with and without these social factors were small and did not meet the meaningfully different criteria. Conclusion(s): Overall, inpatient rehabilitation facility patients' risk-adjusted functional outcomes did not vary meaningfully by dual eligibility status, race or ethnicity, rural residence, socioeconomic status. or living alone. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. There is a wide variation in the curricular emphasis and implementation nationally across programs for teaching quality improvement (QI) in family nurse practitioner (FNP) programs. This variation among curriculum plans often leaves NP graduates unsure as to how to identify and effect change within their organizations. This manuscript describes the development of an initial QI curriculum and subsequent enhancements over a 3-year time frame and outlines the curriculum development process, implementation, and program outcomes within an FNP residency program. This report also focuses on the importance of reinforcing the role of QI within the personal identity of the FNP, ensuring quality care to patients. [ABSTRACT FROM AUTHOR]

An introduction to articles published within the issue is presented including information on the role of healthcare system in supporting the workforce, the need for the healthcare organization to streamline a patient-centered approach and the implementation of moral distress consultation services.

The discipline of geography is an increasingly necessary lens required to understand population-level diseases. Syndemics, or co-occurring diseases or epidemics within a specific population, are contextualized by place--preexisting social, economic, and political structures. Nurse practitioners are well-positioned to critically assess the impact of geography on patient health and well-being. This perspective provides a brief summary of syndemic crises, with a case example in the West Virginia coalfields. The position of this paper is one that supports geography, in addition to social determinants of health, as a framework for syndemics. A geographic perspective provides a more comprehensive picture of marginalized populations and regions facing the phenomenon. Given the significance of holistic nursing, attention to the role of geography in syndemics provides an increased dimension of care and treatment. [ABSTRACT FROM AUTHOR]

Background: Uncontrolled blood glucose may lead to serious complications in patients with type two diabetes mellitus (T2DM). Patients may not have the support, motivation, or encouragement to adhere to the lifestyle changes necessary to control their T2DM. Local problem: More than 75% of the primary care clinic's patients are diagnosed with T2DM, with most patients at the practice site having an average hemoglobin A1c (HbA1c) level of 8.5%. The primary care clinic did not use text messaging to disseminate diabetes self-management education and support (DSMES) as outlined in Standard 4 of the American Diabetic Association's (ADA) clinical practice guideline. Methods: This evidence-based quality improvement project was conducted in a rural outpatient primary care clinic to determine whether implementing the ADA's 2022 National Standards for DSMES using text messaging would affect HbA1C levels among adult patients with T2DM. Interventions: Patients were sent weekly text messages over a 12-week period. Text messages contained information promoting self-care, tips about healthy diet, exercise reminders, instructions about proper blood glucose monitoring, and reminders about medication adherence. Results: A total of 160 patients were included. A paired-sample t-test showed a reduction in HbA1c levels after the intervention from baseline (M = 7.53, SD = 1.72) to postimplementation (M = 6.91, SD = 0.89), t (159) = 11.88, p = .001. Conclusion: Based on the results, implementing the ADA's National Standards for DSMES Standard 4 may affect HbA1c levels in this population. [ABSTRACT FROM AUTHOR]

The Health Resources and Services Administration's (HRSA) Health Center Program provides health care to vulnerable persons across theUS, regardless of their ability to pay for health care.We examined characteristics of populations living within and outside a 30-minute drive-time to HRSA-supported health centers to establish a baseline to better understand the differences in these populations. Using a descriptive, cross-sectional study design and geographic information systems, we found that 94% of persons in the US live within a 30-minute drive-time of a health center. Of those outside a 30-minute drive-time to a health center, 11.7 million (60.11%) are rural and over 1.5 million households (20.32%) lack broadband internet access. [ABSTRACT FROM AUTHOR]

Background: A healthy nursing workforce is vital to ensuring that patients are provided quality care. Assessing nurses' well-being and related factors requires routine evaluations fromhealth systemleaders that leverage brief psychometrically soundmeasures. To date, measures used to assess nurses' well-being have primarily been psychometrically tested among other clinicians or nurses working in specific clinical practice settings rather than in large, representative, heterogeneous samples of nurses. Objectives: This study aimed to psychometrically testmeasures frequently used to evaluate factors linked to nurse well-being in a heterogeneous sample of nurses within a large academic health system. Methods: This cross-sectional, survey-based study used a convenience sample of nurses working across acute care practice settings. A total of 177 nurses completed measures, which included the Professional Quality of Life, the short form of the Professional Quality of Life measure, the two-item Connor-Davidson Resilience Scale, the five-item WorldHealth OrganizationWell-Being Index, the Secondary Traumatic Stress Scale, and the single-item Mini-Z. Internal reliability and convergent validity were assessed for each measure. Results: All the measures were found to be reliable. Brief measures used to assess domains of well-being demonstrated validity with longer measures, as evident by significant correlation coefficients. Discussion: This study provides support for the reliability and validity of measures commonly used to assess well-being in a diverse sample of nurses working across acute care settings. Data from routine assessments of the nursing workforce hold the potential to guide the implementation and evaluation of interventions capable of promoting workplace well-being. Assessments should include psychometrically sound, low-burden measures, such as those evaluated in this study. [ABSTRACT FROM AUTHOR]

Background: Nurse practitioners (NPs) are critical in delivering primary health care, especially in underserved and rural areas. Transitioning from academic training to practical application poses challenges, highlighting the need for structured post-licensure training (PLT). Purpose: To address the knowledge gap regarding the impact of PLT programs on the clinical development, confidence, and care delivery of NPs using an innovative evaluative approach. Methodology: Using a mixed-methods approach, this study engaged 19 NP fellows in quantitative and qualitative evaluations. Assessments of clinical skills and feedback were collected using the REDCap platform, focusing on mentorship and the practical application of skills. Results: Quantitative analysis showed improvements in several domains: patient-centered care (median score increase from 8 to 10, p = .005), knowledge of evidence-based practice (median score from 8 to 9, p = .028), and health systems (median score from 8 to 9, p = .014). Qualitative feedback underscored the benefits of the program's structured support and practical learning experiences while revealing the need for improvements in mentor preparedness. Conclusions: The PLT program effectively advanced NP proficiency across various domains, particularly in patientcentered care and evidence-based practice. However, it also highlighted a crucial need for focused mentorship in developing leadership skills. The study's limited scope, dependence on self-reported measures, and specific statistical methods constrain the broader applicability of its findings. Future research should aim to validate these results across diverse settings and explore long-term outcomes. Implications: This study provides new perspectives on NP workforce development, emphasizing the importance of structured mentorship and training, especially in medically underserved communities. [ABSTRACT FROM AUTHOR]

Objective: To evaluate access to optimal concussion care based on a pediatric patients' geography; the hypothesis is that differential access across the Unites States exists. Design: Employed a novel strategy using internet searches to find local care, mimicking what families might do in different parts of the country. Setting: Virtual internet searches. Participants: Not applicable. Independent Variable: Various metropolitan and rural geographic regions within each state in the United States. Main Outcome Measures: Evaluate access (defined as distance to clinic and ability to see pediatric patients) and optimal care (defined as self-referral process and presence of multidisciplinary care). Results: Search strategy yielded 490 results. Overall; 60% were within 50 miles of searched locations with significant differences in access based on rural versus metropolitan areas (P, 0.0001); in rural areas, only; 22% of results were within 50 miles. Only about one-third of the results (n 5 157) saw pediatric patient with no differences between regions. There was significant regional and geographic variation for optimal care regarding both self-referral processes and access to multidisciplinary care. A diverse group of specialists was represented in search results for concussion care. Conclusions: Nationwide, there is an overall lack of access to multidisciplinary concussion care for pediatric patients. Additionally, those in rural communities face more limitations related to access to facilities with increased distances from closest clinic sites. [ABSTRACT FROM AUTHOR]

Rural communities in the United States are frequently marginalized and misrepresented. These communities face unique challenges, such as limited access to health care, nutritious food, and clean water, that contribute to persistent health disparities. This article presents the CARE (Complex, Access, Resourceful, Extraordinary) framework, which illustrates the dichotomy of rurality—its negative and positive aspects—in order to inform the development of palliative care delivery in rural settings. Various palliative care models are described that address access gaps, bolster provider capacity, and increase the provision of specialty palliative care. However, workforce shortages and reimbursement structures restrict the expansion of these services. Nurses, the largest segment of the health care workforce and the most trusted professionals, must partner with interdisciplinary colleagues and rural communities to advocate for equitable and inclusive care. The authors present the CARE (Complex, Access, Resourceful, Extraordinary) framework, which illustrates the dichotomy of rurality—its negative and positive aspects—in order to inform the development of palliative care delivery in rural settings. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to investigate longitudinal associations between physical activity levels and obesity in adults in Colombia, where participation in large amounts of light-intensity physical activity is a necessity for many people. Methods: Participation in moderate- and vigorous-intensity physical activity was assessed from2005 to 2009, and obesity was assessed from 2011 to 2019 in men and women from the Prospective Urban Rural Epidemiology (PURE) study. Total physical activity level was categorized as low (<600 MET⋅min⋅wk-1), medium (600-3000 MET⋅min⋅wk-1), or high (>3000 MET⋅min⋅wk-1; 600 MET⋅min⋅wk-1 is equivalent to 150 min of moderate activity or 75 min of vigorous activity per week). Obesity was defined as body mass index ≥30 kg⋅m-2. Analyses were adjusted for age, sex, smoking, socioeconomic status, diet, alcohol, sedentary time, and sleep. Results: The main analysis included 3086 men and women aged 51 ± 9 yr at baseline (mean ± SD). Compared with the low physical activity group, the odds ratio (95% confidence interval) for obesity was 0.67 (0.53-0.85) in the medium physical activity group and 0.78 (0.62-0.98) in the high physical activity group after adjustment for potential confounders. Smoking is probably a major confounder, and it is noteworthy that similar associations were observed in participants who reported never smoking. Conclusions: The PURE study is the only prospective cohort study in Colombia. The present analysis is important because it suggests that even the busy people of Colombia could substantially reduce their risk of obesity by participating in moderate- and vigorous-intensity physical activity. [ABSTRACT FROM AUTHOR]

Background: Patients requiring skilled home health care (HH) after hospitalization are at high risk of adverse events. Human factors engineering (HFE) approaches can be useful for measure development to optimize hospital-to-home transitions. Objective: To describe the development, initial psychometric validation, and feasibility of the Hospitalto-Home-Health-Transition Quality (H3TQ) Index to identify patient safety risks. Methods: Development: A multisite, mixed-methods study at 5 HH agencies in rural and urban sites across the United States. Testing: Prospective H3TQ implementation on older adults’ hospital-to-HH transitions. Populations Studied: Older adults and caregivers receiving HH services after hospital discharge, and their HH providers (nurses and rehabilitation therapists). Results: The H3TQ is a 12-item count of hospital-to-HH transitions best practices for safety that we developed through more than 180 hours of observations and more than 80 hours of interviews. The H3TQ demonstrated feasibility of use, stability, construct validity, and concurrent validity when tested on 75 transitions. The vast majority (70%) of hospital-to-HH transitions had at least one safety issue, and HH providers identified more patient safety threats than did patients/caregivers. The most frequently identified issues were unsafe home environments (32%), medication issues (29%), incomplete information (27%), and patients’ lack of general understanding of care plans (27%). Conclusions: The H3TQ is a novel measure to assess the quality of hospital-to-HH transitions and proactively identify transitions issues. Patients, caregivers, and HH providers offered valuable perspectives and should be included in safety reporting. Study findings can guide the design of interventions to optimize quality during the high-risk hospital-to-HH transition. [ABSTRACT FROM AUTHOR]

The clinical role of a clinical officer in Uganda is very similar to that of a physician associate/assistant in the United States. This article describes the qualifications and workforce role of clinical officers in Uganda, as well as their use in two primary care programs that provide effective, low-cost medical care to a growing population with an increasing burden of chronic disease. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic resulted in decreased access to routine diabetes care in rural areas and adversely affected self-management of diabetes. Methods: This article describes a descriptive pretest-posttest study conducted to assess efficacy in managing hemoglobin A1C (A1C) among patients with type 2 diabetes mellitus (T2DM) using a continuous glucose monitoring (CGM) system for 1 year. Results: A total of 14 participants completed the Diabetes Mellitus Self-Efficacy Scale survey. Of those 14, 11 used CGM for 1 year; of the 11 who maintained CGM use, A1C levels improved in 9. Conclusions: Results indicate that CGM combined with medication management positively impacts self-efficacy in managing A1C levels among patients with T2DM. Interdisciplinary collaboration optimizes patient outcomes. The COVID-19 pandemic resulted in decreased access to routine diabetes care in rural areas and adversely affected diabetes self-management. This article describes a descriptive pretest-posttest study conducted to assess efficacy in managing hemoglobin A1C (A1C) among patients with type 2 diabetes mellitus (T2DM) using a continuous glucose monitoring (CGM) system for 1 year. Results indicate that CGM combined with medication management positively impacts self-efficacy in managing A1C levels among patients with T2DM. Interdisciplinary collaboration optimizes patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Postpartum women experience an array of psychological symptoms that are associated with adverse health behaviors and outcomes including postpartum suicidal ideation and long-term depression. To provide early management of postpartum psychological symptoms, it is important to understand how the symptom experiences change over time. Objective: The aim of this study was to examine maternal psychological symptom trajectories over 2, 6, 15, and 24 months postpartum using latent class growth analysis and to examine how each trajectory is associated with maternal depression outcome at 24 months. Methods: We used secondary data from the Family Life Project (N = 1,122) and performed multitrajectory latent class growth analysis based on four observed symptom variables (depression, anxiety, somatization, and hostility). After the final model was identified, bivariate analyses were conducted to examine the association between each trajectory and (a) individual characteristics and (b) outcome (Center for Epidemiologic Studies Depression Scale [CES-D]) variables. Results: A four-class model was selected for the final model because it had better fit indices, entropy, and interpretability. The four symptom trajectories were (a) no symptoms over 24 months, (b) low symptoms over 24 months, (c) moderate symptoms increasing over 15 months, and (d) high symptoms increasing over 24 months. More postpartum women with the trajectory of high symptoms increasing over 24 months (Trajectory 4) were in low economic status (92.16%), unemployed (68.63%), or did not complete 4-year college education (98.04%). Most postpartum women (95.56%) in Trajectory 4 also had higher CES-D cutoff scores, indicating a possible clinical depression at 24 months postpartum. Discussion: Postpartum women who experience increasing symptom trajectories over 15–24 months (Trajectories 3 and 4) could benefit from tailored symptom management interventions provided earlier in the postpartum period to prevent persistent and worsening symptom experiences. [ABSTRACT FROM AUTHOR]

Background: Partnership building and understanding of context that addresses global health concerns is essential in global health research. However, limited knowledge is available on the practical experiences of building such relationships. Objectives: The aim of this study was to provide a detailed description of the processes involved in establishing international collaboration, gain community involvement and cooperation with gatekeepers, and study populations of rural village areas in Western Kenya. Results: Because of the limited information available in the published literature about the extremely important practical considerations, our experiences on the logistical aspects of planning and implementing global health research projects are presented. Conclusion: Understanding the local collaborators and their communities and allocating adequate resources in time and money during the planning phase is paramount in ensuring the successful completion of global health research studies. [ABSTRACT FROM AUTHOR]

The largest healthcare system in New Mexico, in collaboration with the University of New Mexico College of Nursing, identified an opportunity to increase and retain the number of family practice NPs and certified nurse midwives in rural communities by creating an immersive 1-year rural residency program for newly graduated advanced practice registered nurses (APRNs). This article describes the journey to design this program and build its infrastructure with the aim of addressing the needs of both APRNs during their transition to practice and patients in rural areas, while providing a return on the healthcare system's business investment. Program results are also reported. Program funding was provided by a Health Resources and Services Administration grant, the Presbyterian Healthcare Services executive team, and the Presbyterian Healthcare Foundation. The largest healthcare system in New Mexico, in collaboration with the University of New Mexico College of Nursing, identified an opportunity to increase and retain the number of family practice NPs and certified nurse midwives in rural communities by creating an immersive 1-year rural residency program for newly graduated advanced practice registered nurses (APRNs). This article describes the journey to design this program and build its infrastructure with the aim of addressing the needs of both APRNs during their transition to practice and patients in rural areas, while providing a return on the healthcare system's business investment. Program results are also reported. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study is to explore variations in access to spasticity chemodenervation specialists across several geographical, ethnic, racial, and population density factors. Design: This is a retrospective cross-sectional study on Medicare Provider Utilization and Payment Data. Providers with substantial adult spasticity chemodenervation practices were included. Ratios were assessed across geographical regions as well as hospital referral regions. A multivariate linear regression model for the top 100 hospital referral regions by beneficiary population was created, using backward stepwise selection to eliminate variables with P values > 0.10 from final model. Results: A total of 566 providers with spasticity chemodenervation practices were included. Unadjusted results showed lower access in nonurban versus urban areas in the form of higher patient:provider ratios (83,106 vs. 51,897). Access was also lower in areas with ≥25% Hispanic populations (141,800 vs. 58,600). Multivariate linear regression results showed similar findings with urban hospital referral regions having significantly lower ratios (−45,764 [ P = 0.004] vs. nonurban) and areas with ≥25% Hispanic populations having significantly higher ratios (+96,249 [ P = 0.003] vs. <25% Hispanic areas). Conclusions: Patients in nonurban and highly Hispanic communities face inequities in access to chemodenervation specialists. The Medicare data set analyzed only includes 12% of the US patient population; however, this elderly national cross-sectional cohort represents a saturated share of patients needing access to spasticity chemodenervation therapy. Future studies should venture to confirm whether findings are limited to this specialization, and strategies to improve access for these underserved communities should be explored. [ABSTRACT FROM AUTHOR]

This innovative project was funded by the Health Resources and Services Administration (HRSA) Nursing Workforce Diversity (NWD) grant (2017), with a resultant increase in the diversity of the nursing workforce in the rural Pee Dee Region of South Carolina. The project provided resources to at-risk students (n = 100) and compared participants with a control group (n = 92). The project provided participants mentors, financial assistance, experiential learning, advising, and professional development. The project descriptively compared program outcome benchmarks between groups. The project's multifaceted approach was key to success, providing implications for other programs to increase diversity of the nursing workforce. [ABSTRACT FROM AUTHOR]

Background: Electronic nicotine delivery systems (ENDS), also known as e-cigarettes, are the most commonly used tobacco products among young adults in the United States. Young adults in rural areas have a higher prevalence of ENDS use compared to their urban counterparts, yet there is limited evidence regarding the in-depth understanding of experiences and perspectives directly from young adults. Objectives: The aim of this study was to explore individual experiences and perspectives about use and cessation of ENDS from young adults in rural areas. Methods: This was a qualitative study using interpretive description for analysis. Young adults (18-24 years) who used ENDS every day but not other tobacco products (cigarettes, smokeless, etc.) in the past month and had an address in a rural county of Wisconsin were eligible; there were nine participants interviewed using Zoom. Interview questions focused on initial use, maintenance of use, experiences of quitting, and social and rural environmental contexts regarding ENDS. Results: Three themes emerged with eight categories: (a) addiction to ENDS and health, (b) cessation and resources, and (c) rural environment and culture in ENDS addiction. Discussion: Findings have implications for ENDS cessation interventions targeting young adults in rural areas. [ABSTRACT FROM AUTHOR]

Rural children in agricultural communities are thought to more likely be exposed to cholinesterase-inhibiting insecticides that may have enduring health effects than are urban children. This article shows that blood cholinesterase measures reflect these rural-urban differences that likely follow insecticide exposures. Regulations to protect rural residents from environmental insecticide exposures should be strengthened. Objective: In a 2-group prospective design, this study compared seasonal cholinesterase levels of Latinx children in rural farmworker families and comparable urban children to assess the impact of environmental exposure to cholinesterase-inhibiting insecticides. Methods: Quarterly blood samples and passive dosimeter wristbands were collected over 2 years in 8-year-old children (74 rural, 62 urban). Laboratory analysis assessed total cholinesterase, acetylcholinesterase, and butyrylcholinesterase from blood samples, and insecticides from wristbands. Results: In spring and summer, total cholinesterase and acetylcholinesterase levels were depressed in rural children compared with winter and fall. Butyrylcholinesterase was depressed in rural children in fall compared with spring and summer. Adjustment for insecticide exposure did not affect these associations. Conclusions: Environmental exposures to cholinesterase-inhibiting insecticides have measurable biochemical effects on blood cholinesterases in rural children from farmworker families. [ABSTRACT FROM AUTHOR]

Although there have been some researches focusing on temperature and respiratory diseases, few studies have focused specifically on suburban rural villages or semi-arid regions. In current study, we evaluated the effects of extreme temperatures on hospital admissions for respiratory diseases in suburban rural areas, a semi-arid region in Northwest China. Objective: This study evaluated the effects of extreme temperatures on hospital admissions for respiratory diseases (RDs) in a semi-arid region in the Northwest of China. Methods: Distributed lag nonlinear model was constructed, and stratified analysis by gender and age was performed. Results: The exposure–response curve between temperature and RD hospital admissions was almost W-shaped. Either extremely cold temperatures or moderately cold temperatures presented a short-term acute harmful effect, and the relative risks were higher among males (1.976, 95% confidence interval [CI]: 1.773–2.203; 1.242, 95% CI: 1.203–1.282) and the elderly (2.363, 95% CI: 1.724–3.240; 1.267, 95% CI: 1.154–1.390). Both extreme and moderately hot temperatures had higher risks among females (2.040, 95% CI: 1.815–2.292; 1.328, 95% CI: 1.276–1.381). Conclusions: The relationship between air temperature and RD hospital admissions was nonlinear. Vulnerable populations varied according to extreme temperature conditions. [ABSTRACT FROM AUTHOR]

Objective: The objective of this project was to promote evidence-based practice and identify how to best implement nutrition education interventions for adults living in rural and/or low-income communities. Introduction: Adults living in rural and/or low-income communities are at increased risk for poor nutrition and chronic health conditions. Patients are referred to the EversCare Clinic (ECC), an ambulatory clinic at an academic medical center in Mississippi, USA, to receive assistance with social needs. In addition to living in rural and/or low-income communities, over 90% of the patients seen at the ECC are food-insecure, yet nutrition education is inconsistently provided. Methods: The JBI Practical Application of Clinical Evidence System (PACES) and the Getting Research into Practice (GRiP) audit and feedback tools were used. The ECC team conducted a baseline audit of 30 patient electronic health records, designed and implemented best-practice nutrition education strategies, and completed a follow-up audit of 30 patient electronic health records. Four evidence-based criteria for nutrition education in adults living in rural and/or low-income communities were audited, and various interventions were used to address multiple levels. Results: The baseline audit revealed patients were not receiving recommended nutrition education interventions. Following the implementation, there was a 64.2% improvement in compliance with all four best practice criteria. Involving nursing students proved to be an effective method of improving compliance. Conclusion: Adherence to best practices regarding implementing nutrition education interventions was satisfactory, with 80% of patients receiving interventions at individual, interpersonal, community, and societal levels. Future audits are planned to ensure sustainability. [ABSTRACT FROM AUTHOR]

Objective: This study describes firefighters' on-scene decontamination procedure use post-working fire and frequency of adherence to best practice. Methods: This retrospective analysis of working fires was conducted using records from the ESO Data Collaborative (Austin, TX) national research database from January 1, 2021, to December 31, 2021. Documentation of decontamination procedures was examined among records with smoke or combustion products exposure. Firefighter and incident characteristics were evaluated. Descriptive statistics and univariable odds ratios were calculated. Results: Among the 31,281 firefighters included in the study, 8.0% documented a fire-related exposure. Of those, 82% performed at least one on-scene decontamination procedure; 5% documented all decontamination procedures defined as best practices. The odds of documenting any decontamination procedure were significantly decreased among firefighters responding to incidents in rural areas compared with urban areas (odds ratio, 0.70). Conclusions: Fire personnel may not be taking all necessary decontamination steps post-working fires. [ABSTRACT FROM AUTHOR]

BACKGROUND: Regional variation in complex healthcare is shown to negatively impact health outcomes. We sought to characterize geographic variance in esophageal cancer operation in Michigan. STUDY DESIGN: Data for patients with locoregional esophageal cancer from the Michigan Cancer Surveillance Program from 2000 to 2013 was analyzed. We reviewed the incidence of esophageal cancer by county and region, and those with locoregional disease receiving an esophagectomy. Counties were aggregated into existing state-level "urban vs rural" designations, regions were aggregated using the Michigan Economic Recovery Council designations, and data was analyzed with ANOVA, F-test, and chi-square test. RESULTS: Of the 8,664 patients with locoregional disease, 2,370 (27.4%) were treated with operation. Men were significantly more likely to receive esophagectomy than women (p < 0.001). Likewise, White, insured, and rural patients were more likely than non-White (p < 0.001), non-insured (p = 0.004), and urban patients (p < 0.001), respectively. There were 8 regions and 83 counties, with 61 considered rural and 22 urban. Region 1 (Detroit metro area, southeast) comprises the largest urban and suburban populations; with 4 major hospital systems it was considered the baseline standard for access to care. Regions 2 (west; p = 0.011), 3 (southwest; p = 0.024), 4 (east central; p = 0.012), 6 (northern Lower Peninsula; p = 0.008), and 8 (Upper Peninsula; p < 0.001) all had statistically significant greater variance in annual rates of operation compared with region 1. Region 8 had the largest variance and was the most rural and furthest from region 1. The variance in operation rate between urban and rural differed significantly (p = 0.005). CONCLUSIONS: A significant increase in variation of care was found in rural vs urban counties, as well as in regions distant to larger hospital systems. Those of male sex, White race, rural residence, and those with health insurance were significantly more likely to receive operation. [ABSTRACT FROM AUTHOR]

Rehabilitation is important in the care of patients with cancer for improving function, pain, and quality of life. However, only a small number of clinicians are formally trained in cancer rehabilitation. Virtual learning environments may play a promising role in cancer rehabilitation education, especially in the coronavirus pandemic era where in-person learning is not readily available. A national, interprofessional cancer rehabilitation education program involving a monthly longitudinal webinar series and a 2-day virtual bootcamp was developed through the US Department of Veterans Affairs Extension for Community Healthcare Outcomes to improve Department of Veterans Affairs clinician understanding of cancer rehabilitation and ultimately increase the availability of cancer rehabilitation services in the Veterans Health Administration. From March 2020 to July 2022, 923 individuals participated with an average of 72 participants per session and 204 participants per session in the bootcamp. Participants' most common disciplines were physical therapy, occupational therapy, nursing, medicine (physicians), advanced practice providers, speech therapy, and pharmacy. Participants reported improved knowledge of cancer rehabilitation and anticipated that the knowledge would change their practice. Virtual education can be a useful means to educate Department of Veterans Affairs–based healthcare professionals about cancer rehabilitation and improve access to rehabilitation services for veterans with cancer. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer (CRC) is a leading cause of death from cancer in the United States, despite the availability of high-quality screening options. Multiple barriers to CRC screening have been identified, including cost (noninsured), younger age, racial or ethnic minority, recent immigration to the United States (non-English speaking), fear or distrust of the health care system, and rural residence. Local Problem: The mean CRC screening rate for the designated Federally Qualified Health Center (FQHC) was 33.7% for the 5 months preceding this quality improvement (QI) project. The benchmark target for CRC screening was 60.1%. Methods: The Model for Improvement and Plan-Do-Study-Act cycle created the framework for the CRC screening targeted interventions used in this FQHC patient population. Interventions: Multiple targeted interventions were implemented over a 4-month period that emphasized a strong provider recommendation, a team-based approach to identify and offer CRC screening options to the overdue patient. A chart audit was followed by a mailed fecal immunochemical test (FIT) and colonoscopy reminder letter initiative. Results: The performance metric for CRC screening reached 40% within 4 months. A second chart audit confirmed the CRC screening rate improved to 41.5% among patients aged 50–75 years. An overall 55% return rate was achieved with the mailed FIT initiative within 2 months. Conclusions: Continued quality improvement initiatives are needed to achieve the benchmark target for this FQHC. These team-based interventions can be used by the primary care nurse practitioner to improve health equity for CRC screening in other underserved populations. [ABSTRACT FROM AUTHOR]

Background: This article identifies the independent predictors of falls in an implementation study of Tai Ji Quan: Moving for Better Balance® (TJQMBB) in older adults in rural West Virginia churches. Methods: Falls and injuries were identified via calendars, questionnaire, and verbal reports. Results: Fall predictors were gait speed (odds ratio [OR]: 0.27; 95% confidence interval [CI]: 0.08-0.90); low back pain (OR: 8.04; 95% CI: 1.71-37.79); and pain, stiffness, or swelling limiting activity (OR: 2.44; 95% CI: 1.09-5.45). Conclusions: Determining differences between fallers and nonfallers may identify people with different fall risk profiles and ultimately better tailor fall prevention programming to individual needs. [ABSTRACT FROM AUTHOR]

The article focuses on instructions for completing an online continuing education (CE) test related to a nursing article, including registration, test-taking procedures, and information on earning contact hours.

Food insecurity in the United States is a public health crisis and particularly impacts individuals in rural areas.1 Efforts to improve food access, including pilot programs to increase online ordering, have reduced food insecurity and improved diet quality for participants enrolled in supplemental nutrition programs.3,4 We discuss the nutritional and economic benefits of public and private partnerships that enhance the supplemental nutrition programs of the United States Department of Agriculture Food and Nutrition Service (eg, Special Supplemental Nutrition Program for Women, Infants, and Children; Supplemental Nutrition Assistance Program), and propose the expansion of technology and transportation resources through public and private partnerships to better address rural food insecurity. [ABSTRACT FROM AUTHOR]

BACKGROUND: Medicaid expansion impacted patients when assessed at a national level. However, of the 32 states that expanded Medicaid, only three were Southern states. Whether results apply to Southern states that share similar geopolitical perspectives remains elusive. We aimed to assess the impact of Medicaid expansion on breast cancer diagnosis and treatment in 8 Southern states in the US. STUDY DESIGN: We identified uninsured or Medicaid patients (age 40 to 64 years) diagnosed with invasive breast cancer from 2011 to 2018 in Southern states from the North American Association of Central Cancer Registries--Cancer in North America Research Dataset. Medicaid-expanded states ([MES], Louisiana, Kentucky, Arkansas) were compared with non-MES ([NMES], Tennessee, Alabama, Mississippi, Texas, Oklahoma) using multivariate logistic regression and differences-in-differences analyses during pre- and postexpansion periods; p < 0.05 was considered statistically significant. RESULTS: Among 21,974 patients, patients in MES had increased odds of Medicaid insurance by 43% (odds ratio 1.43, p < 0.01) and decreased odds of distant-stage disease by 7% (odds ratio 0.93, p = 0.03). After Medicaid expansion, Medicaid patients increased by 10.6% in MES (Arkansas, Kentucky), in contrast to a 1.3% decrease in NMES (differences-in-differences 11.9%, p < 0. 0001, adjusting for age, race/ethnicity, rural-urban status, and poverty status). MES (Arkansas, Kentucky) had 2.3% fewer patients diagnosed with distant-stage disease compared with a 0.5% increase in NMES (differences-in-differences 2.8%, p = 0.01, after adjustment). Patients diagnosed in MES had higher odds of receiving treatment (odds ratio 2.27, p = 0.03). CONCLUSIONS: Unlike NMES, MES experienced increased Medicaid insured, increased treatment, and decreased distant-stage disease at diagnosis. Medicaid expansion in the South leads to earlier and more comprehensive treatment of breast cancer. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Despite the potential for telemedicine in public libraries to expand health care access to those living a long distance from care and in broadband poor areas, there are few libraries that collaborate with providers to extend access. Purpose: To explore licensed health care providers' perspectives on telemedicine in public libraries as a method of improving equitable access to care for populations lacking the ability to connect to telemedicine from home. Methods: We used a two-phase explanatory sequential mixed methods design with a quantitative strand followed by a qualitative strand. Surveys were analyzed descriptively. Interviews were analyzed thematically using descriptive content analysis. Results: Of the 50 survey respondents, 13 were physicians and 36 were nurse practitioners (NPs); 12 NPs were interviewed. NPs were overwhelmingly supportive of telemedicine in public libraires, describing how connecting at-risk populations to a video visit (VV) allowed for a more thorough and accurate assessment than a phone call. Although several NPs were concerned with privacy, others considered a library to be more private than the home. Interviews revealed how chronic illness management may be the ideal visit type for public library-based telemedicine. Conclusions: Given the importance of expanding access sites for telemedicine, NPs should consider partnering with libraries in their catchment areas where broadband access is sparse and patients must travel long distances to care. Implications: Managing chronic illnesses using telemedicine in public libraries may be an important approach toward reducing health disparities in populations who live in long distances from care and do not have home-based internet access. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Increasing access to opioid use disorder (OUD) treatment is critical to curbing the opioid epidemic, particularly for rural residents who experience numerous health and health care disparities, including higher overdose death rates and limited OUD treatment access compared with urban dwellers. Buprenorphine–naloxone is an evidence-based treatment for OUD that is well suited for rural areas. However, providers must have a specialized federal waiver to prescribe the medication. Despite the acceleration of the opioid epidemic in rural areas and the recent liberalization of federal buprenorphine–naloxone prescribing laws, few providers hold buprenorphine–naloxone prescribing waivers and even fewer prescribe the medication. Purpose: This study explores barriers and facilitators to buprenorphine–naloxone prescribing among nurse practitioners (NPs) working in primary care settings in eastern North Carolina. Methodology: Individual interviews were conducted with 13 NPs working in primary care settings in eastern North Carolina. Qualitative thematic analysis was used to identify perceived barriers and facilitators to buprenorphine–naloxone prescribing. Results: Analysis found prescribing barriers related to OUD stigma, perceived knowledge, federal and state regulation, and prescribing resources and found facilitators related to adopting a person-centered approach, developing prescriber skills, and access to prescribing resources. Conclusions: The barriers and facilitators that NPs experience related to buprenorphine prescribing for OUD are similar to those faced by physicians, although the barriers arguably more profound. Future research should consider how to mitigate these prescribing barriers to facilitate NP buprenorphine prescribing for OUD. Implications: To our knowledge, this is the first qualitative study of NP buprenorphine–naloxone prescribing in rural areas. Given the prominence of OUD in rural regions and the key role NPs play in primary care provision, this study lays import groundwork for developing interventions to support buprenorphine–naloxone prescribing by NPs practicing in rural regions. [ABSTRACT FROM AUTHOR]

Purpose: Hopelessness and rurality are each independently associated with increased mortality in adults with ischemic heart disease (IHD), yet there is no known research examining hopelessness in rural patients with IHD. The authors of this study evaluated the reliability and validity of the State-Trait Hopelessness Scale (STHS) in a primarily rural population of adults with IHD living in West North Central United States (US Great Plains). Methods: Reliability, concurrent validity, and convergent validity were evaluated for 115 adults hospitalized for IHD. Rural-Urban Commuting Area codes were used to stratify participants by rurality level, with 66% categorized as rural. Principal component analysis was used to examine potential factor structure of the STHS. Findings: Cronbach α for the State and Trait Hopelessness subscales were 0.884 and 0.903, respectively. Concurrent validity was supported for the State and Trait subscales using the Patient Health Questionnaire-8 (State: r = 0.50, P <.001; Trait: r = 0.35, P <.001). Convergent validity was supported for the State subscale using the Duke Activity Status Index (r = −0.23, P =.013). Principal component analysis showed 2 factors (hopelessness present and hopelessness absent) for the State and Trait subscales, accounting for 63% and 58% of variance, respectively. Conclusions: Findings support the reliability and validity of the STHS for evaluation of hopelessness in rural adults with IHD in clinical and research settings. Results replicated the same factor structure found in testing of the STHS in a primarily urban sample. Because of the prevalence of hopelessness in rural adults with IHD and association with increased mortality, hopelessness should be assessed during hospitalization and in the recovery period. [ABSTRACT FROM AUTHOR]

Background: Heart diseases are one of the leading causes of health-related deaths among children. Concurrent hospice care offers hospice and nonhospice healthcare services simultaneously, but the use of these services by children with cardiac disease has been rarely investigated. Objective: The aims of this study were to identify patterns of nonhospice healthcare services used in concurrent hospice care and describe the profile of children with cardiac disease in these clusters. Methods: This study was a retrospective cohort analysis of Medicaid claims data collected between 2011 and 2013 from 1635 pediatric cardiac patients. The analysis included descriptive statistics and latent class analysis. Results: Children in the sample used more than 314 000 nonhospice healthcare services. The most common services were inpatient hospital procedures, durable medical equipment, and home health. Latent class analysis clustered children into "moderate intensity" (60.0%) and "high intensity" classes (40.0%). Children in "moderate intensity" had dysrhythmias (31.7%), comorbidities (85.0%), mental/behavioral health conditions (55%), and technology dependence (71%). They commonly resided in urban areas (60.1%) in the Northeast (44.4%). The health profile of children in the "high intensity" class included dysrhythmias (39.4%), comorbidities (97.6%), mental/behavioral health conditions (71.5%), and technology dependence (85.8%). These children resided in rural communities (50.7%) in the South (53.1%). Conclusions: Two patterns of use of nonhospice healthcare services were identified in this study. This information may be used by nurses and other healthcare professionals working in concurrent hospice care to assess the healthcare service needs of children with cardiac conditions at the end of life. [ABSTRACT FROM AUTHOR]

Increasing hospital and labor & delivery (L&D) closures have led to declining access to hospital obstetric care in rural areas across the country. These closures increase the burden on women and families living in rural communities, who often must drive long distances for prenatal visits and delivery. The lack of maternal health care in rural America can also result in several adverse maternal and infant outcomes including premature birth, low birth weight, out of hospital births, maternal and infant morbidity and mortality, and increased risk of postpartum depression. The reasons for these closures are multifactorial, and include, workforce shortages, financial viability, low volume of patients, concerns over maintaining the knowledge base and skill sets of the obstetrical health care team required to provide high quality and safe care, as well as medical-legal concerns. The problems of providing and accessing quality maternal and obstetrical care in rural America have not happened overnight, Likewise, the solutions to these problems will also not occur overnight and must also address the multifactorial nature of the problem. However, there are several opportunities to improve access to maternal health care in rural communities. Programs, policies, and funding need to be designed and provided to make these opportunities a reality. [ABSTRACT FROM AUTHOR]

Representation in data sets is critical to improving healthcare for the largest possible number of people. Unfortunately, pregnancy is a very understudied period of time. Further, the gap in available data is wide between pregnancies in urban areas versus rural areas. There are many limitations in the current data that is available. Herein, we review these limitations and strengths of available data sources. In addition, we propose a new mechanism to enhance the granularity, depth, and speed with which data is made available regarding rural pregnancy. [ABSTRACT FROM AUTHOR]

There is great evidence to support improved maternal and neonatal outcomes when a patient delivers in a center that is suited to the needs of both the birthing person and the fetus. As rural centers have closed, access remains challenging. This manuscript examines The Emergency Medical Treatment and Labor Act, Emergency Medical Services (EMS) challenges, needs of rural hospitals including education, and elaborates further upon the need to expand maternal transport in rural areas to improve outcomes in the future. [ABSTRACT FROM AUTHOR]

The United States is in the midst of a maternity care crisis. A key driver is workforce shortages, which impacts maternity care service delivery in rural areas significantly. The midwifery model of care remains underutilized. Midwifery care delivered by certified nurse-midwives and certified midwives is heavily endorsed and supported in the extant literature, but no firm national actions have been taken to move recommendations into funding or practice. Certified nurse-midwives and Certified Midwives are able to care for low-risk pregnancies and are uniquely situated to address factors associated with social determinants of health in rural areas. One of the solutions to the rural maternity care crisis is scaling up the midwifery workforce. Individual, institutional, state, and federal factors are discussed. [ABSTRACT FROM AUTHOR]

Of the 28 million rural women of reproductive age in the United States, ∼7 million of them live in areas of limited access to maternity care. While only 6.7% of Family Physicians currently provide maternity care, they are the only delivering physicians in 27% of rural hospitals. Of the 1.6% of Family Physicians performing cesarean deliveries as a primary surgeon, 57.3% do so in a rural county and 38.6% do so in a county without an obstetrician. Cultivation of the next generation of Family Physicians providing maternity care is essential to prevent further spread of existing maternity care deserts. [ABSTRACT FROM AUTHOR]

In the United States, skin cancer is a prevalent and sometimes preventable form of cancer that causes a significant disease burden in rural and urban communities. Studies have shown, however, that rural residents are less likely to engage in primary prevention behaviors against skin cancer, and rural populations have higher skin cancer incidence and mortality than urban residents. Teledermatology can be used to address disparities in both skin cancer diagnosis and health education to improve dermatology outcomes in rural communities. This article reviews teledermatology formats, barriers, and benefits to encourage integration of teledermatology modalities into clinical practice. [ABSTRACT FROM AUTHOR]

The article offers information on the current status of food assistance programs in the United States, focusing on the U.S. Department of Agriculture's (USDA's) efforts. Topics discussed include the decrease in federal spending on these programs in 2023; the distribution of funds across major programs like Supplemental Nutrition Assistance Program (SNAP) & Child Nutrition Programs; and the participation trends in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

Chronic obstructive pulmonary disease remains a challenging epidemic across the United States. This serious illness impacts nearly twice as many individuals in the rural area compared with urban counterparts. As the disease progresses, the symptom burden and needs of the patient and caregivers escalate. Access gaps to services, such as hospice and palliative care, and the social determinants of health found in Appalachia may lead to marginalization and social injustice. Defined as the condition of being peripheralized based upon one's social margins of identity, associations, and/or environment, marginalization impacts health outcomes and quality of life. This article explores the triple threat of marginalization for patients with chronic obstructive pulmonary disease living in rural Appalachia. By recognizing marginalization and designing initiatives to reduce the impact, hospice and palliative care nurses serve as advocates and leaders to influence systemic change through partnerships with key policymakers and legislators. [ABSTRACT FROM AUTHOR]

Understanding musculoskeletal disorders and the associated difficulty when performing daily work can inform in-depth research into musculoskeletal disorder risk factors during farm work and lead to creation of interventions to improve rural workers' quality of life. Objective: Musculoskeletal disorders (MSDs) are common among farmers, yet associated difficulty during work is not well understood. The purpose of this study was to determine the connection between MSDs and work-related task difficulty in rural Saskatchewan. Methods: Rural Saskatchewan farmers and farm workers with history of MSD in the last 5 years (n = 72) participated via an online survey. Results: Shoulder MSDs were the most common (75%), followed by neck (65%), knees (61%), and lower back (58%). Many participants reported more than one MSD. Presence of MSDs leads to difficulty in work tasks; for example, difficulty when operating power tools with hands was 8.7 times more likely for those with shoulder MSD. Conclusions: MSDs in rural Saskatchewan farmers are associated with greater work task difficulty, and future research into risk factors related to those tasks can guide prevention strategies. [ABSTRACT FROM AUTHOR]

Background: Screening for lung cancer is an evidence-based but underutilized measure to reduce the burden of lung cancer mortality. Lack of adequate data on geographic availability of lung cancer screening inhibits the ability of healthcare providers to help patients with decision-making and impedes equity-focused implementation of screening-supportive services. Objectives: This analysis used data from the 2012–2016 Surveillance, Epidemiology, and End Results (SEER) Program, the Behavioral Risk Factor Surveillance System, and the county health ranking to examine (a) which cancer resources and county-level factors are associated with late-stage lung cancer at diagnosis and (b) associations between county rurality and lung cancer incidence/mortality rates. Methods: Using the New York state SEER data, we identified 68,990 lung cancer patients aged 20–112 years; 48.3% had late-stage lung cancers, and the average lung cancer incidence and mortality rates were 70.7 and 46.2 per 100,000, respectively. There were 144 American College of Radiology-designated lung cancer screening centers and 376 Federally Qualified Health Centers identified in New York state. County rurality was associated with a higher proportion of late-stage lung cancers and higher lung cancer mortality rates. Discussion: Visual geomapping showed the scarcity of rural counties' healthcare resources. County rurality is a significant factor in differences in lung cancer screening resources and patient outcomes. Use of publicly available data with geospatial methods provides ways to identify areas for improvement, populations at risk, and additional infrastructure needs. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated the relative importance of job-, community-, and individual-related factors that contribute to job choice among physicians, physician assistants (PAs), and NPs, to inform policy options to recruit clinicians to rural areas. Methods: A cross-sectional online survey of PA preceptors from three institutions in two states. Participants were asked to rate the importance of 16 job-, community-, and individual-related factors when choosing a job. Results: We received responses from 45 physicians, 74 PAs, and 15 NPs (24.2% response rate), who rated most job-, community-, and individual-related factors as important; ratings were similar across clinicians. PAs rated loan repayment programs and work hours higher than physicians, though the magnitude of the difference was small. Conclusions: Clinicians similarly rated many factors as important. A better understanding of the tradeoffs clinicians are willing to make between these factors when making a job choice is critical to increase the attractiveness of rural positions. [ABSTRACT FROM AUTHOR]

Hospital closings and scarce obstetrical staff undermine access. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: The leading cause of injuries among older adults in the United States is unintentional falls. The American Geriatrics Society/British Geriatrics Society promote fall risk management in primary care; however, this is challenging in low-resource settings. Local Problem: Archer Family Health Care (AFHC), an Advanced Practice Registered Nurse (APRN)–managed and federally designated rural health clinic, identified a care gap with falls adherence to guidelines for patients at higher risk for falls. Methods: The aim of this quality improvement effort was to integrate an evidence-based fall risk management tool in a rural nurse-managed primary care practice. A standardized fall risk management process with a new brief paper-based clinical decision support (CDS) tool was developed and tested in two phases. Intervention: Phase 1 focused on developing a fall risk management CDS tool, identifying the primary care visit workflow, communicating the workflow patterns to the AFHC staff, and collaborating with the staff to identify when and who should implement the tool. Phase 2 focused on implementation of the fall risk management CDS tool into standard practice among older adults aged 65 years and older. Results: We found that integrating the tool did not disrupt the workflow of primary care visits at AFHC. The most common recommended intervention for patients at risk of falling was daily vitamin D supplementation. Conclusion: This project revealed that it is feasible to introduce a brief fall risk management decision support tool in an APRN-managed rural primary care practice. [ABSTRACT FROM AUTHOR]

Purpose: There is a paucity of global data on sedentary behavior during early childhood. The purpose of this study was to examine how device-measured sedentary behavior in young children differed across geographically, economically, and sociodemographically diverse populations, in an international sample. Methods: This multinational, cross-sectional study included data from 1071 children 3–5 yr old from 19 countries, collected between 2018 and 2020 (pre-COVID). Sedentary behavior was measured for three consecutive days using activPAL accelerometers. Sedentary time, sedentary fragmentation, and seated transport duration were calculated. Linear mixed models were used to examine the differences in sedentary behavior variables between sex, country-level income groups, urban/rural settings, and population density. Results: Children spent 56% (7.4 h) of their waking time sedentary. The longest average bout duration was 81.1 ± 45.4 min, and an average of 61.1 ± 50.1 min·d−1 was spent in seated transport. Children from upper-middle–income and high-income countries spent a greater proportion of the day sedentary, accrued more sedentary bouts, had shorter breaks between sedentary bouts, and spent significantly more time in seated transport, compared with children from low-income and lower-middle–income countries. Sex and urban/rural residential setting were not associated with any outcomes. Higher population density was associated with several higher sedentary behavior measures. Conclusions: These data advance our understanding of young children's sedentary behavior patterns globally. Country income levels and population density appear to be stronger drivers of the observed differences, than sex or rural/urban residential setting. [ABSTRACT FROM AUTHOR]