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Arsenic contamination in groundwater threatens public health, particularly in small, low-income communities lacking affordable treatment solutions. This study investigated the field implementation of novel air cathode assisted iron electrocoagulation (ACAIE) technology for arsenic removal in Allensworth, California, where groundwater arsenic concentrations exceeded 250 µg/L. Over four months, a pilot-scale ACAIE system, operating at 600 L/h, consistently reduced arsenic levels to below the EPA’s maximum contaminant level of 10 µg/L. Laboratory experiments informed the optimization of charge dosage and flow rates, which were validated during field testing of the ACAIE 600 L/h system. The in-situ generation of hydrogen peroxide at the cathode speeded up the reaction kinetics, ensuring high arsenic removal efficiency while allowing high throughput, even with a compact reactor size. An economic analysis demonstrated a treatment cost of USD 0.02/L excluding labor, highlighting the system’s affordability compared to conventional methods. Adding labor costs increased the treatment cost to USD 0.09/L. The regeneration of air cathodes extended their operational life, addressing a key maintenance challenge, thus reducing the costs slightly. Intermittent challenges were encountered with filtration and secondary contaminant removal; these issues highlight opportunities for further operational improvements. Despite these challenges, ACAIE’s low operational complexity, scalability, and cost-effectiveness make it a promising solution for underserved small communities. These findings provide critical insights into deploying sustainable arsenic remediation technologies that are tailored to the needs of rural, low-resource communities.

ObjectiveLittle is known about how the COVID-19 pandemic affected cancer screenings among American Indian people residing in California and Oklahoma, 2 states with the largest American Indian populations. We assessed rates and factors associated with cancer screenings among American Indian adults during the pandemic.MethodsFrom October 2020 through January 2021, we surveyed 767 American Indian adults residing in California and Oklahoma. We asked participants whether they had planned to obtain screenings for breast cancer, cervical cancer, and colorectal cancer (CRC) from March through December 2020 and whether screening was postponed because of COVID-19. We calculated adjusted odds ratios (AORs) for factors associated with reasons for planned and postponed cancer screening.ResultsAmong 395 participants eligible for breast cancer screening, 234 (59.2%) planned to obtain the screening, 127 (54.3%) of whom postponed it. Among 517 participants eligible for cervical cancer screening, 357 (69.1%) planned to obtain the screening, 115 (32.2%) of whom postponed it. Among 454 participants eligible for CRC screening, 282 (62.1%) planned to obtain CRC screening, 80 of whom (28.4%) postponed it. In multivariate analyses, women who lived with a child (vs did not) had lower odds of planning to obtain a breast cancer screening (AOR = 0.6; 95% CI, 0.3-1.0). Adherence to social distancing recommendations was associated with planning to have and postponement of cervical cancer screening (AOR = 7.3; 95% CI, 0.9-58.9). Participants who received (vs did not receive) social or financial support had higher odds of planning to have CRC screening (AOR = 2.0; 95% CI, 1.1-3.9).ConclusionThe COVID-19 pandemic impeded completion of cancer screenings among American Indian adults. Interventions are needed to increase the intent to receive evidence-based cancer screenings among eligible American Indian adults.

Substantial evidence indicates that medical mistrust, resulting from experiences with discrimination and marginalisation, is a determinant of health disparities in minority populations. However, this research is largely limited to the US and other industrialised countries. To broaden our understanding of the role of medical mistrust on health-care decision making, we conducted a study on healthcare experiences and perceptions in a rural, underserved indigenous community in northwest Namibia (n = 86). Mixing semi-structured interview questions with the medical mistrust index (MMI), we aim to determine the relevance of the MMI in a non-industrialised population and compare index scores with reports of healthcare experiences. We find that medical mistrust is a salient concept in this community, mapping onto negative healthcare experiences and perceptions of discrimination. Reported healthcare experiences indicate that perceived incompetence, maltreatment and discrimination drive mistrust of medical personnel. However, reporting of recent healthcare experiences are generally positive. Our results indicate that the concept of medical mistrust can be usefully applied to communities in the Global South. These populations, like minority communities in the US, translate experiences of discrimination and marginalisation into medical mistrust. Understanding these processes can help address health disparities and aid in effective public health outreach in underserved populations.

BACKGROUND: Access to evidence-based treatments such as family-based therapy (FBT) is difficult for adolescents diagnosed with Anorexia Nervosa (AN) living in rural or regional areas due to a limited trained workforce, high staff turnover and inconsistent treatment fidelity. Telehealth offers a potential access solution by facilitating care irrespective of family or service location. The disruption to the health system caused by COVID-19 amplified an existing need and increased the use of telehealth to deliver FBT before its efficacy and safety was fully evaluated. This study aimed to evaluate the feasibility, acceptability and preliminary efficacy of telehealth-FBT delivered by community-based clinicians within rural services directly into the home to reduce the eating disorder symptoms of adolescents diagnosed with AN. METHODS: A pre- and post-implementation multi-site case series delivered up to 20 sessions of telehealth-FBT to 28 adolescents (89.29% female, M = 14.68 ± 1.58 years) living in rural or regional Australia. The RE-AIM framework guided the evaluation, with Reach (treatment uptake and completion); Efficacy (change in weight, global eating disorder symptoms, and remission from baseline to end of treatment and six-month follow-up); Adoption (patient characteristics and drop out); Implementation (intervention fidelity) and Maintenance (outcomes and intervention during the follow-up period) used to assess the feasibility and preliminary efficacy of telehealth-FBT. RESULTS: There was a high level of interest in telehealth-FBT, with two-thirds of eligible families consenting to participate. Both treatment engagement and completion rates were over 60%, and treatment was delivered with acceptable fidelity. Twenty adolescents (71.43%) met the diagnostic criteria for AN (baseline 86.03%mBMI ± 7.14), and eight (28.57%) for Atypical AN (baseline 101.34%mBMI ± 8.28), with an overall mean duration of illness of 8.53 months (SD = 5.39, range 2-24 months). There was a significant increase in %mBMI at the end of treatment compared to the baseline (p = 0.007, 95%CI: 1.04-6.65), with over 68% of adolescents weight restored and 36.8% of these achieving both weight and psychological remission criteria. Weight remained significantly improved at six-month follow-up (p = 0.005, 95%CI: 1.57-8.65). Also, there was a decrease in adolescents global eating disorder symptoms, as rated by their parents, at the end of treatment compared to the baseline of 0.735 (p = 0.028, 95%CI: 0.079-1.385). CONCLUSIONS: Telehealth-FBT was feasibly implemented into rural services and delivered by community clinicians with reach, adoption, preliminary efficacy, and fidelity scores comparable to those reported by specialist studies. TRIAL REGISTRATION: The study was conducted according to the HREC-approved protocol (HREC 2020/ETH00186) and registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR # 12620001107910).

Infectious diseases exploit niches that are often spatially defined as urban and/or rural. Yet spatial research on infectious diseases often fails to define "urban" and "rural" and how these contexts might influence their epidemiology. We use dengue fever, thought to be mostly an urban disease with rural foci, as a device to explore local definitions of urban and rural spaces and the impact of these spaces on dengue risk in the provinfine urban and rural locales. Interviews conducted from 2019 to 2021 with 71 residents and 23 health personce of Esmeraldas, Ecuador. Ecuador, like many countries, only uses population size and administrative function to denel found that they identified the availability of basic services, extent of their control over their environment, and presence of underbrush and weeds (known in Ecuador as monte and maleza and conceptualized in this paper as natural disorder) as important links to their conceptions of space and dengue risk. This broader conceptualization of space articulated by local residents and professionals reflects a more sophisticated approach to characterizing dengue risk than using categories of urban and rural employed by the national census and government. Rather than this dichotomous category of space, dengue fever can be better framed for health interventions in terms of specific environmental features and assemblages of high-risk spaces. An understanding of how community members perceive risk enhances our ability to collaborate with them to develop optimal mitigation strategies.

BackgroundVentricular ablation may be clinically indicated for patients with recurrent ventricular tachycardia (VT) and has been shown to decrease risk of recurrence and overall morbidity. However, the existence of disparities among patients receiving ventricular ablation has not been well characterized.ObjectivesIn this study, the authors examined patients hospitalized with VT to determine whether disparities exist among those receiving ablations.MethodsThe authors used the National Inpatient Sample to assess patients hospitalized with a primary diagnosis of VT in 2019 who did and did not receive catheter ablations. Multiple logistic regression was used to calculate risk factors for VT ablation based on age, sex, race/ethnicity, socioeconomic status, and hospital characteristics.ResultsAfter adjusting for baseline characteristics and comorbidities, female and Black patients hospitalized with VT had significantly lower odds of receiving ablations compared with male and White patients (OR: 0.835; 95% CI: 0.699-0.997; P = 0.047; and OR: 0.617; 95% CI: 0.457-0.832; P = 0.002, respectively). Additionally, patients at rural or nonteaching hospitals were significantly less likely to receive ablations compared with those at urban, teaching hospitals. No significant differences were noted based on income or insurance status in the adjusted models.ConclusionsThe authors identified significant disparities in the delivery of ventricular ablations among patients hospitalized with VT. Overall, patients who were female or Black as well as those who were hospitalized at rural or nonteaching hospitals were significantly less likely to receive VT ablations during hospitalization.

Background: Telemedicine remains an underused tool in rural emergency medical servces (EMS) systems. Rural emergency medical technicians (EMT) and paramedics cite concerns that telemedicine could increase Advanced Life Support (ALS) transports, extend on-scene times, and face challenges related to connectivity as barriers to implementation. Our aim in this project was to implement a telemedicine system in a rural EMS setting and assess the impact of telemedicine on EMS management of patients with chest pain while evaluating some of the perceived barriers.Methods: This study was a mixed-methods, retrospective review of quality assurance data collected prior to and after implementation of a telemedicine program targeting patients with chest pain. We compared quantitative data from the 12-month pre-implementation phase to data from 15 months post-implementation. Patients were included if they had a chief complaint of chest pain or a 12-lead electrocardiogram had been obtained. The primary outcome was the rate of ALS transport before and after program implementation. Secondary outcomes included EMS call response times and EMS agency performance on quality improvement benchmarks. Qualitative data were also collected after each telemedicine encounter to evaluate paramedic/EMT and EMS physician perception of call quality.Results: The telemedicine pilot project was implemented in September 2020. Overall, there were 58 successful encounters. For this analysis, we included 38 patients in both the pre-implementation period (September 9, 2019–September 10, 2020) and the post-implementation period (September 11, 2020–December 5, 2021). Among this population, the ALS transport rate was 42% before and 45% after implementation (odds ratio 1.11; 95% confidence interval 0.45–2.76). The EMS median out-of-service times were 47 minutes before, and 33 minutes after (P = 0.07). Overall, 64% of paramedics/EMTs and 89% of EMS physicians rated the telemedicine call quality as “good.”Conclusion: In this rural EMS system, a telehealth platform was successfully used to connect paramedics/EMTs to board-certified EMS physicians over a 15-month period. Telemedicine use did not alter rates of ALS transports and did not increase on-scene time. The majority of paramedics/EMTs and EMS physicians rated the quality of the telemedicine connection as “good.”

BACKGROUND: Gestational diabetes mellitus (GDM) is a common pregnancy complication with long-term health consequences for mothers and their children. The escalating trends of GDM coupled with the growing prevalence of maternal obesity, a significant GDM risk factor projected to approach nearly 60% by 2030 in Kansas, has emerged as a pressing public health issue. METHODS: The aim of this study was to compare GDM and maternal obesity trends in rural and urban areas and investigate maternal demographic characteristics influencing the risk of GDM development over a 15-year period. Trend analyses and a binary logistic regression were employed utilizing 2005 to 2019 de-identified birth record vital statistics from the Kansas Department of Health and Environment (N = 589,605). RESULTS: Over the cumulative 15-year period, a higher prevalence of GDM was observed across age, race/ethnicity, education, and insurance source. Throughout this period, there was an increasing trend in both GDM and obese pre-pregnancy BMI age-adjusted prevalence, with noticeable rural-urban disparities. From 2005 to 2019, women, including Asians (OR: 2.73, 95% CI 2.58%-2.88%), American Indian or Alaskan Natives (OR: 1.58, 95%, CI 1.44-1.73%), Hispanics (OR: 1.42, 95% CI 1.37%-1.48%), women residing in rural areas (OR: 1.09, 95%, CI 1.06-1.12%), with advanced maternal age (35-39 years, OR: 4.83 95% CI 4.47%-5.22%; ≥40 years, OR: 6.36 95%, CI 5.80-6.98%), with lower educational status (less than high school, OR: 1.15, 95% CI 1.10%-1.20%; high school graduate, OR: 1.10, 95% CI 1.06%-1.13%), Medicaid users (OR: 1.10, 95% CI 1.06%-1.13%), or with an overweight (OR: 1.78, 95% CI 1.72%-1.84%) or obese (OR: 3.61, 95% CI 3.50%-3.72%) pre-pregnancy BMI were found to be at an increased risk of developing GDM. CONCLUSIONS: There are persistent rural-urban and racial/ethnic disparities present from 2005 to 2019 among pregnant women in Kansas with or at-risk of GDM. There are several socioeconomic factors that contribute to these health disparities affecting GDM development. These findings, alongside with prominent rising maternal obesity trends, highlight the need to expand GDM services in a predominantly rural state, and implement culturally-responsive interventions for at-risk women.

Several studies have reported immune modulation by organophosphate (OP) pesticides, but the relationship between OP exposure and SARS-CoV-2 infection is yet to be studied. We used two different measures of OP pesticide exposure (urinary biomarkers (N = 154) and residential proximity to OP applications (N = 292)) to examine the association of early-childhood and lifetime exposure to OPs and risk of infection of SARS-CoV-2 using antibody data. Our study population consisted of young adults (ages 18-21 years) from the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) Study, a longitudinal cohort of families from a California agricultural region. Urinary biomarkers reflected exposure from in utero to age 5 years. Residential proximity reflected exposures between in utero and age 16 years. SARS-CoV-2 antibodies in blood samples collected between June 2022 and January 2023 were detected via two enzyme linked immunosorbent assays, each designed to bind to different SARS-CoV-2 antigens. We performed logistic regression for each measure of pesticide exposure, adjusting for covariates from demographic data and self-reported questionnaire data. We found increased odds of SARS-CoV-2 infection among participants with higher urinary biomarkers of OPs in utero (OR = 1.94, 95% CI: 0.71, 5,58) and from age 0-5 (OR = 1.90, 95% CI: 0.54, 6.95).

Although widely acknowledged as an important social determinant of health, until recently researchers and policymakers have primarily approached housing insecurity as an urban issue, obscuring the visibility of its impacts in rural contexts, including the ways in which housing insecurity intersects with other health and structural inequities facing rural populations. Working to address this gap in the existing literature, this paper explores the experiences of housing insecurity in a rural context by reporting on an analysis of 210 in-depth interviews with 153 adults between the ages of 18-35, living in California's rural North State, a relatively overlooked far northern region of the state comprised of 12 north central and north eastern counties. Using in-depth qualitative interview data, we conducted an exploratory pattern-level analysis of participants' narratives structured by four dimensions of housing insecurity defined in the literature (housing affordability, housing stability, housing conditions, and neighborhood context). Drawing attention to the pervasiveness of rural housing insecurity within our sample, this analysis highlights the unique ways in which rurality creates distinct experiences not currently captured in the existing literature. Further research is needed across different types of rural communities to better understand the various ways that housing insecurity affects the everyday lives and health of rural residents. By grounding research within the experiences of rural residents, we are better able to respond to the crisis of rural housing insecurity and develop solutions that are tailored to rural residents' unique needs.

PurposeAmong Latina breast cancer survivors, explore associations between rural/urban residence and health-related quality of life (HRQL), and whether associations are moderated by financial strain and low neighborhood cohesion.MethodsWe combined baseline data from two randomized controlled trials of a stress management intervention conducted among 151 urban and 153 rural dwelling Latinas with nonmetastatic breast cancer. Generalized linear models estimated associations between rural/urban status and HRQL (overall, emotional, social-family, physical, and functional well-being), and we examined moderation effects of financial strain and low neighborhood cohesion, controlling for age, marital status, and breast cancer characteristics.ResultsRural women reported better emotional (β = 1.85; 95% CI = 0.37, 3.33), functional (β = 2.23; 95% CI = 0.69, 3.77), and overall (β = 5.68; 95% CI = 1.12, 10.25) well-being than urban women, regardless of degree of financial strain or neighborhood cohesion; moderation effects were not statistically significant. Financial strain was inversely associated with emotional (β = -2.34; 95% CI = 3.63, -1.05), physical (β = -2.56; 95% CI = -4.12, -1.01), functional (β = -1.61; 95% CI = -2.96, -0.26), and overall (β = -6.67; 95% CI = -10.96, -2.98) well-being. Low neighborhood cohesion was inversely associated with emotional (β = -1.27; 95% CI = -2.50, -0.04), social-family (β = -1.72; 95% CI = -3.02, -0.42), functional (β = -1.63; 95% CI = -2.92, -0.34), and overall (β = -5.95; 95% CI = 9.76, -2.14) well-being.ConclusionsRural Latina breast cancer survivors reported better emotional, functional and overall well-being than their urban counterparts. Greater financial strain and less neighborhood cohesion were associated with worse HRQL on most domains regardless of rural/urban context.Implications for cancer survivorsInterventions that focus on increasing perceived neighborhood cohesion and reducing or better managing financial strain, could help improve Latina cancer survivors' well-being.

This study evaluated the measurement invariance of a neuropsychological battery across rural and urban older adults from Costa Rica. Rural and urban older adults (N = 295) from the Epidemiology and Development of Alzheimer's Disease (EDAD) study in Costa Rica were assessed. The baseline factor model for the EDAD neuropsychological measures was identified with nine neuropsychological measures and three cognitive constructs: Verbal Memory, Spatial Reasoning, and Cognitive Flexibility. Measurement and structural invariance were established, and, then, group comparisons of the latent cognitive factors were conducted to explore regional disparities. The findings showed that most of the neuropsychological tests in EDAD can be directly compared across the groups, allowing for cognitive constructs comparisons. The rural sample showed a disadvantage in the Spatial Reasoning and Cognitive Flexibility abilities. When age and education were included in the models, differences between the regions disappeared. Having more years of education was associated with higher cognitive abilities, with a larger effect for the rural group. Norms for Costa Rican older adults should consider age and education adjustments. This study contributes to the growing area of measurement invariance in neuropsychological assessment as it highlights the importance of examining the comparability of assessment measures across different cultural groups.

ImportanceResearch on fetal epigenetic programming suggests that the intrauterine environment can have long-term effects on offspring disease susceptibility.ObjectiveTo examine the association between prenatal maternal occupation and child epigenetic age acceleration (EAA) among a farmworker community.Design, setting, and participantsThis cohort study included participants in the Center for the Health Assessment of Mothers and Children of Salinas, a prospective, Latino, prebirth cohort. Pregnant women were recruited from October 1, 1999, to October 1, 2000, from 6 community clinics in California's Salinas Valley agricultural region. Participants were 18 years or older, English or Spanish speaking, Medicaid eligible, and at 20 weeks' gestation or earlier at enrollment. Mother-child pairs who had blood DNA methylation measured at the ages of 7, 9, and 14 years were included. Data were analyzed from July 2021 to November 2023.ExposuresPrenatal maternal occupation was ascertained through study interviews conducted during prenatal visits and shortly after delivery.Main outcomes and measuresChild EAA at 7, 9, and 14 years of age was estimated using DNA methylation-based epigenetic age biomarkers. Three EAA measures were calculated: the Horvath EAA, skin and blood EAA, and intrinsic EAA. Linear mixed-effects models were used to estimate longitudinal associations of prenatal maternal occupation and child EAA, adjusting for confounders and prenatal organophosphate pesticide exposure.ResultsAnalyses included 290 mother-child pairs (mean [SD] maternal age at delivery, 26.5 [5.2] years; 152 [52.4%] female infants); 254 mothers (87.6%) were born in Mexico, 33 (11.4%) in the US, and 3 (1.0%) in other countries; and 179 families (61.7%) were below the federal poverty line during pregnancy. Mothers reported engaging in several types of work during pregnancy, including agricultural fieldwork (90 [31.0%]), other agricultural work (40 [13.8%]), nonagricultural work (53 [18.3%]), or no work (107 [36.9%]). Children whose mothers worked in agricultural fields during pregnancy had a mean of 0.66 (95% CI, 0.17-1.15) years of greater Horvath EAA, 0.62 (95% CI, 0.31-0.94) years of greater skin and blood EAA, and 0.45 (95% CI, 0.07-0.83) years of greater intrinsic EAA compared with children whose mothers did not work during pregnancy.Conclusions and relevanceIn this cohort study, prenatal maternal agricultural fieldwork was associated with accelerated childhood epigenetic aging independent of organophosphate pesticide exposure. Future research on which factors related to agricultural fieldwork accelerate aging in the next generation can inform targeted prevention programs and policies that protect children's health.

BackgroundThe penetrance of common genetic risk variants for Parkinson's disease (PD) is low. Pesticide exposure increases PD risk, but how exposure affects penetrance is not well understood.ObjectiveTo determine the relationship between occupational pesticide exposure and PD in people with LRRK2 and GBA risk variants.MethodsParticipants of the Parkinson's Progression Markers Initiative (PPMI) with a LRRK2-G2019 S or GBA risk variant provided information about occupational pesticide exposure. We compared exposure in carriers with and without PD. Among carriers with PD, we used Cox proportional hazard models to compare time-to impairment in balance, cognition, and activities of daily living (ADLs) between participants with and without prior occupational pesticide exposure.Results378 participants with a risk variant provided exposure information; 176 with LRRK2-G2019 S (54 with and 122 without PD) and 202 with GBA variants (47 with and 155 without PD). Twenty-six participants reported pesticide exposure. People with a GBA variant and occupational pesticide exposure had much higher odds of PD (aOR: 5.4, 95% CI 1.7-18.5, p

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IX: people and places-diverse populations and locations of care', authors address the following themes: 'LGBTQIA+health in family medicine', 'A family medicine approach to substance use disorders', 'Shameless medicine for people experiencing homelessness', '''Difficult" encounters-finding the person behind the patient', 'Attending to patients with medically unexplained symptoms', 'Making house calls and home visits', 'Family physicians in the procedure room', 'Robust rural family medicine' and 'Full-spectrum family medicine'. May readers appreciate the breadth of family medicine in these essays.

AimsTo investigate the trajectory, influencing factors and dynamic relationships between fear of cancer recurrence (FCR) and quality of life (QOL) in lung cancer patients.DesignProspective longitudinal study.MethodsLongitudinal data from 310 lung cancer patients across three hospitals in China were assessed at 1, 3, 6 and 12 months postoperatively (T1 -T4 ). Descriptive statistics characterised patient demographics, clinical characteristics, levels of FCR and QOL. A linear mixed-effects model was employed to analyse FCR trajectories, identify influencing factors on these trajectories, and predict the impact of FCR on QOL.ResultsFCR changed significantly over time, with a slight decrease during T1 -T2 , an increase at T3 and gradual decline at T4 . Higher fear levels were associated with female sex, suburban or rural residency, being a family breadwinner, presence of comorbidities and negative coping behaviours, and low family resilience. QOL negatively correlated with FCR, and FCR predicted lower QOL.ConclusionsAt 3 and 6 months postoperatively, lung cancer patients, especially women, suburban or rural residents, family breadwinners, those with comorbidities, negative coping behaviours and low family resilience, reported high levels of FCR. Healthcare providers should pay special attention to lung cancer patients especially during the period of 3-6 months post-surgery and offer tailored interventions to improve their QOL.Implications for the profession and patient careUnderstanding the FCR trajectories, its influencing factors and its negative impacts on QOL can guide the development of targeted interventions to reduce fear and enhance well-being in patients with cancer.ImpactIdentifying the trajectories and influencing factors of fear of lung cancer recurrence in patients at different time points informs future research on targeted interventions to improve QOL.Reporting methodThe study adhered to the guidelines outlined in the Statement on Reporting Observational Longitudinal Research.

ObjectiveMost work on place-based (e.g., rural-urban) health disparities has been conducted with population-level data, which is limited in its capacity for causal inferences about individuals and lifespan health. The present study leverages individual-level longitudinal data, spanning up to 29 years, to understand how rurality-urbanicity predicts risk for all-cause mortality; whether these associations hold above and beyond socioeconomic status (SES); and whether the association between rurality-urbanicity and mortality risk varies by sex, SES, race, ethnicity, and partner status.MethodThe present preregistered study uses data from two large longitudinal studies of U.S. Americans (Health and Retirement Study and Midlife in the United States; total N = ∼55,000), who reported on their sociodemographic characteristics, had their addresses linked to geographical indicators (i.e., rural-urban continuum codes), and have data from the National Death Index regarding the vital status and survival time.ResultsUsing Cox proportional hazards regression models, findings showed that suburban and rural residents were at a 12% and 18% greater risk for earlier mortality compared to urban residents in Health and Retirement Study, but the associations between rurality-urbanicity and mortality risk were nonsignificant in Midlife in the United States. The longitudinal associations between rurality-urbanicity and mortality risk were largely independent of SES. Finally, there was only one statistically significant interaction effect, suggesting the strength and direction of the association between rurality-urbanicity and mortality risk was largely the same across sociodemographic subgroups.ConclusionsThere is tentative evidence suggesting that rurality-urbanicity is an important social determinant of longevity, over and above other sociodemographic factors. Future studies should explore how to promote longer and healthier lives among rural residents. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

ObjectivesThe objective of this study was to describe the use of telemedicine for contraception in a sample of young adults and examine differences by health insurance coverage.Study designWe analyzed survey data collected from May 2020 to July 2022 from individuals at risk of pregnancy aged 18 to 29 recruited at 29 community colleges in California and Texas. We used multivariable mixed-effects logistic regression models with random effects for site and individual to compare the use of telemedicine to obtain contraception by insurance status, sociodemographic characteristics, and state.ResultsOur analytic sample included 6465 observations from 1630 individuals. Participants reported using a contraceptive method obtained through telemedicine in just 6% of observations. Uninsured participants were significantly less likely than those privately insured to use contraception obtained through telemedicine (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.31-0.97), as were participants who did not know their insurance status (aOR, 0.54; 95% CI, 0.29-0.99). Texas participants were less likely to use contraception obtained via telemedicine than those in California (aOR, 0.42; CI: 0.25-0.69).ConclusionsFew young people in this study obtained contraception through telemedicine, and insurance was crucial for access in both states.ImplicationsAlthough telemedicine holds promise for increasing contraceptive access, we found that few young adults were using it, particularly among the uninsured. Efforts are needed to improve young adults' access to telemedicine for contraception and address insurance disparities.

Background: In developing countries, the delivery of medical care to rural residents has been experiencing long-standing challenges and disparities. Since the 1960s, China has established the village doctors' system to provide preventive and primary care to improve rural residents' health. Nevertheless, how village doctors affect the medical spending and the end-of-life (EOL) quality for older people in rural China has not received sufficient attention. Family care has long been the mainstream of old age care in rural China, the accessibility to appropriate medical care is hence crucial. Village doctors are the most accessible medical care providers for rural older people. As a result, this study aims to uncover the importance of village doctors in EOL medical care for rural older people in China. Methods: The analysis is based on the Chinese Longitudinal Healthy Longevity Survey (CLHLS), which has national representativeness and contains information about the oldest old at an average age of 80 in China, with available information from 2002 to 2019. We adopt the quantile regression to illustrate the heterogeneous impacts of village doctors on the EOL medical care spending from the distribution perspective. We then employ the ordered logit model and ordinary least squares regression to estimate the effects of village doctors on rural older people's EOL life quality measured by the status before dying and the number of bedridden days. Results: We find that the EOL medical care spending is significantly increased by the presence of village doctors, especially high-quality ones. The disparities in the EOL medical care in rural and urban China are significantly reduced by high-quality village doctors. However, high-quality village doctors are still insufficient to meet the needs of rural older people regarding the high-end EOL medical care. The empirical results suggest that village doctors can significantly improve older people's quality of life before death in rural China. Conclusion: Our analysis highlights the importance of village doctors in providing EOL medical care to older people in rural China. It is crucial for governments to improve the village doctors' system, so that older residents in rural China can obtain high-quality EOL medical care services in their own communities and have a better quality of life before death. [ABSTRACT FROM AUTHOR]

Introduction: Self-reported illnesses (SRI) surveys are widely used as a low-cost substitute for weak Disease Surveillance Systems in low- and low-middle-income countries. In this paper, we report findings of a district-level disease prevalence survey of all types of illnesses including chronic, infectious, injuries and accidents, and maternal and child health in a rural district in Pakistan. Methods: A district-level survey was conducted in Thatta in 2019 with a population-representative sample of all ages (n = 7811) a. Survey included questions on demographics and SRIs from the respondents. Prevalence was estimated for all SRIs categorized into six major and 16 minor illnesses. The influence of important socio-demographic covariates on the illnesses and multiple comorbidities was explored by estimating prevalence ratios with a Generalized Linear Model of the Poisson family and by Zero-Inflated Poison Distribution respectively. Findings: 36.57% of the respondents to the survey reported at least one SRI. Prevalence of communicable illnesses was 20.7%, followed by non-communicable illnesses (4.8%), Gastrointestinal disorders (4.4%), and injuries/disabilities (1.9%). Urban inhabitants were more likely to have Chronic Obstructive Pulmonary Disorders (3.34%) and Diabetes (1.62%). Females were most likely to have injuries (1.20,), disabilities (1.59), and Musculoskeletal Disorders (1.25). Children aged < 1 year (0.80) and elderly >65 years (0.78) were more likely to have comorbidities. Discussion: Our estimated prevalence of SRI is quite higher than the prevalence of unknown SRIs in national-level surveys in Pakistan. This research's findings serve as an example of aiding evidence-based priority settings within the health sector. Our findings on gender, and young and old age as positive predictors of SRI are consistent with similar surveys in a few LMICs. Recommendation and conclusion: We provide evidence of a complete disease profile of a district that is otherwise unavailable in the country. This study can reshape the existing health surveys and to aid evidence-based priority settings in the health sector. We, however, support strengthening the Disease Surveillance System as a reliable source of disease prevalence data. [ABSTRACT FROM AUTHOR]

Background: Research shows that trauma team formation could potentially improve effectiveness of injury care in rural settings. The aim of this study was to determine the feasibility of rural trauma team training amongst medical trainees and traffic law enforcement professionals in Uganda. Methods: Prospective multi-centre interrupted time series analysis of an interventional training based on the 4th edition of rural trauma team development course of the American College of Surgeons. Trauma related multiple choice questions (MCQs), and trauma non-technical skills were assessed pre-and post-training between September 2019- August 2023. Acceptability of the training for promulgation to other rural regions and its relevance to participants' work needs were evaluated on 5- and 3-point Likert scales respectively. The median MCQ scores (IQR) were compared before and after training at 95% CI, regarding p < 0.05 as statistically significant. Triangulation with open-ended questions was obtained. Time series regression models were applied to test for autocorrelation in performance using Stata 15.0. Ethical approval was obtained from Uganda National Council for Science and Technology (Ref: SS 5082). Results: A total of 500 participants including: 66 (13.2%) traffic police officers, 30 (6.0%) intern doctors, 140 (28.0%) fifth year and 264 (52.8%) third-year medical students were trained. Among the 434 medical trainees who completed the trauma-based MCQ assessment, the median pre- and post-test scores were 60%, IQR (50–65) and 80%, IQR (70–85) respectively. Overall, the mean difference between pre- and post-test scores was statistically significant (z = 16.7%, P|z|=<0.0001). Most participants strongly agreed to promulgate 389 (77.8%), relevance to their educational 405 (81.0%), and work needs 399 (79.8%). Each of the course components was rated above 76.0% as being very relevant. There was an overall increment in median (IQR) trauma-nontechnical skills team performance scores from 12 (9-14) to 17 (15-20) after the training (p < 0.001), with police teams advancing from 9.5 (6.0-12.5) to 19.5 (17.0-21.5) (p < 0.001). Conclusion: This study demonstrates that rural trauma team development training had a positive effect on the test scores of course participants. The training is feasible, highly acceptable and regarded as relevant amongst medical trainees and traffic law enforcement professionals who provide first-aid to trauma patients in resource-limited settings. The findings could inform the design of future trauma teams in rural communities. Trial registration: Retrospective registration (UIN: researchregistry9450). Key highlights: • There is limited human and infrastructural resources for trauma care in Low-and-middle-income countries (LMICs). • Research shows that trauma education could increase the effectiveness of injury care in remote settings. • We explore the feasibility of rural trauma team development training through an educational intervention, viewing rural medical trainees and traffic law enforcement professionals as sustainable human resources for health, and discuss policy implications for LMICs. [ABSTRACT FROM AUTHOR]

Background: Most research on tracking practice locations of health students has focused on medical students, particularly the factors influencing their choice to work in rural and remote areas. However, there is limited research on how rural origin and training in regional or rural settings affect the employment destinations of dental and oral health graduates. This paper explores the practice locations of dentistry and oral health therapy (OHT) graduates from rural backgrounds compared to those from metropolitan areas in Australia. Materials and methods: The target population was dental and OHT graduates from La Trobe University's Rural Health School (Australia) who completed their studies between 2009 and 2023. The graduates' primary place of practice was sourced from the Australian Health Practitioners Regulation Agency (AHPRA) data. The 2019 Modified Monash Model (MMM) was used to categorise the students' original place of residence by rurality and practice locations. Multivariable analyses were conducted to explore the association between home and practice locations while controlling for the effect of socio-demographic characteristics collected from students at enrolment. Results: Data were available for 819 graduates matched to the AHPRA register. Of these, 541 (66.1%) were dentists, and 278 (33.9%) were OHTs. The majority were female (56.7% dentists and 81.7% OHTs), 11.3% (dentists) and 21.6% (OHTs) of the graduates originated from rural and remote areas, 16.6% (dentists) and 18% (OHTs) from regional areas, and 72.1% (dentists) and 60.4% (OHTs) from metropolitan areas. Multinomial logistic regression analyses for dentists and OHTs identified that , having a regional background, or having a rural or remote background were the most significant predictors for regional, rural/remote practice over metropolitan areas. Conclusion: Regional background is the strongest predictor for graduate dentists and OHTs practicing in Australia's regional or rural and remote locations. Similarly, students from rural and remote locations were highly likely to practice in rural/ remote locations. Increasing the recruitment of students with rural backgrounds may positively impact graduates' decisions to practice in rural areas. [ABSTRACT FROM AUTHOR]

Background: Shared decision-making in healthcare is a collaborative process where patients are supported to make informed decisions according to their preferences. Healthcare decisions affect patients' lives which necessitates patients to participate in decisions concerning their health. This study explored experiences and ethical issues related to shared decision-making in a rural healthcare setting. Methods: An exploratory qualitative study was conducted at Budumba Health Centre III and Butaleja Health Centre III in rural Eastern Uganda. In this study, 23 in-depth interviews were conducted among 12 healthcare providers and 11 patients. Data was analyzed thematically using NVivo-12 plus software. Results: Four themes emerged which included: Paternalistic cultures of care, challenges, strategies for improvement, and ethical issues. Patients at both facilities expressed the need to be involved in decision-making processes. However, many stressed that they are not engaged in decision-making about their health. Many healthcare providers noted that shared decision-making could improve patient prognosis but are faced with challenges related to low male involvement and the influence of cultural and religious practices, including myths and patriarchal attitudes which impact effective patient engagement. Ethical issues identified include concerns about informed consent, privacy and confidentiality, deception, and harm. Conclusions: This study highlighted the need for better sensitization of patients and comprehensive training for healthcare providers to minimize and resolve ethical issues that emerge during shared decision-making processes. Therefore, targeted interventions are needed to enhance decision-making processes in rural healthcare including but not limited to developing shared decision-making manual and continuous training of healthcare providers to ethically engage patients. Further research is needed to explore larger facilities with a bigger scope including patients under 18 years of age and and their surrogates. [ABSTRACT FROM AUTHOR]

Traditional foodways are under threat due to historical factors like profound racial discrimination, alongside the pressures of a highly capitalised and industrialised food system and environmental degradation. In the northern Cederberg mountains of South Africa, bread-making forms an integral part of the cultural heritage of rural communities and has evolved in response to social, environmental, economic, and epistemic changes. Using semi-structured interviews and the use of participatory workshops to give voice to food-based practical knowledge, we identified the primary drivers for foodway transitions in these remote areas. They included changes in land access, use, and climate, as well as modernisation, economic development, and urbanisation. Through articulating the voices of local foodways custodians, we reveal the indispensable role that food plays in affirming identity, culture, and connections to land. Our findings underscore the importance of local food cultures in enhancing the well-being and health of rural communities, and the way they entwine connections between humans and the more-than-human natural world. [ABSTRACT FROM AUTHOR]

Background: The UN General Assembly recognised the human right to water and sanitation through the sixth SDG in 2010. South Kordofan, a state in southern Sudan, faces WASH challenges due to conflict, geographical factors, and inadequate services, impacting over 600,000 residents. Such conflicts are well known for spreading diseases and disrupting WASH-related practices among displaced individuals. Objectives: The study aimed to evaluate the quality and availability of drinking water, as well as sanitation and hygiene practices in rural South Kordofan. It also sought to identify factors affecting community satisfaction with WASH services and to establish a data-driven basis for future interventions addressing these issues. Methods: A cross-sectional study accompanied a medical mission to South Kordofan, selecting 33 villages from South Kordofan based on healthcare, population, and accessibility. Water samples, patient forms and questionnaires were collected using convenient sampling for targeted villages and for attendants of mobile clinics. Laboratory analyses were conducted on water samples. Descriptive statistics, univariate analysis and logistic regression were used to analyse the data. The used level of significance was 0.05. Results: Out of 784 participants, 60.2% were female. Tube wells/boreholes were the primary water source (68.1%), and most participants (70.9%) lived near their water source (less than 30 min). Dissatisfaction with water services was reported by 56.8%, and satisfaction associated with method of delivery (OR = 0.081, CI = 0.024–0.276)), appearance (OR = 0.299, CI = 0.182–0.489), distance (OR = 0.264, CI = 0.099–0.705), water unavailability (OR = 0.477, CI = 0.297–0.765), and obligation to pay (OR = 0.351, CI = 0.185–0.665). Samples showed high levels of contamination, both microbial and physicochemical. Regarding sanitation, over a third of the participants (41.5%) disposed of children's stool by leaving it outdoors. About 10% of the participants reported having diarrhea during the week before the study. However, about two-thirds of the participants (68.1%) showed good hygienic practices by using soap or detergents for hand washing. Conclusion: The study revealed inadequate WASH services, high microbial contamination, and poor water treatment practices. Paradoxically, many participants expressed satisfaction with water services. Sanitation issues and open defecation persist, emphasizing the need for comprehensive interventions. All these negative consequences can be attributed to the armed conflict which resulted in poor awareness about the safety of drinking water, what safe water looks like and proper hygiene practices. Moreover, these conflicts led to disruption of the economical status leading to the absence of proper water purification infrastructure. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to explore young rural women's perceived barriers in accessing healthcare services with a focus on the interrelation between three marginalization criteria: age (youth), gender (female), and place of residence (rural areas) in Australia, Canada, and Sweden. Methods: Using a qualitative interpretive approach, we conducted semi-structured in-depth interviews with 31 young women aged 18 to 24 in selected rural communities. Data collection took place from May 2019 to January 2021, and the qualitative data were analyzed using NVivo software. Results: Self-perceived barriers for access to healthcare services among young women living in rural and remote areas encompass various challenges across individual, institutional, and structural levels. Individual barriers include limited knowledge about available health services, negative attitudes toward healthcare, psychological discomfort when seeking assistance, and economic affordability issues. Institutional challenges involve limited healthcare resources, gender insensitivity among providers, judgmental attitudes from healthcare staff, inadequate time management of services, and a lack of privacy and confidentiality within facilities. Structural barriers further compound these issues through socio-cultural and gender norms, insufficient coverage of universal health insurance, low budget allocations for health facilities in rural and small urban areas, and the geographic distance to healthcare providers. Addressing these multifaceted barriers is crucial to improving healthcare access for rural population. Conclusions: Appropriate strategies and policies must be introduced to promote access to healthcare services in rural and remote areas even in most high-'income countries. [ABSTRACT FROM AUTHOR]

The digital economy injects new vitality into rural revitalization and new-type urbanization to achieve rural industrial transformation, while the countryside and the city provide the soil for the development of the digital economy. This research establishes the rural revitalization (RR), new-type urbanization (NU), and digital economy (DE) system and uses the coupled coordination degree (CCD) model and obstacle degree (OD) model to study the spatiotemporal evolution characteristics and obstacle factors of the composite system in China from 2011 to 2021. The result showed that: (1) the comprehensive development level of the composite systems is on an upward trend year by year, but still shows a low-quality state; (2) the CCD of China's provinces shows a spatial evolution pattern of high in the east and low in the west; (3) The obstacle factors of the RR, NU, DE subsystem are mainly involved the number of rural doctors and health workers, local financial income per capita and science and technology expenditure, and the digital finance coverage breadth index. These results suggested that Strengthening the synergy between China's urban-rural integrated development and digital construction in the future hinges upon providing valuable decision-making insights to facilitate the pursuit of regionally differentiated development and the achievement of sustainable development goals. [ABSTRACT FROM AUTHOR]

The health disparities between rural and urban populations in Australia, driven by socioeconomic, environmental, and healthcare access factors, highlight the urgent need for rural-focused medical education. The Melbourne Medical School's Rural Health Discovery program addresses this need by integrating adult learning principles within a redesigned curriculum that includes the Rural Health Foundations and Integrating Rural Health topics. These Discovery topics engage medical students from diverse backgrounds through a blend of self-directed learning, problem-solving, and immersive clinical placements in rural settings. By aligning with andragogical principles—such as fostering autonomy, practical relevance, and experiential learning—the program prepares students for the unique demands of rural healthcare practice. Students are introduced to the complexities of rural health, including the social determinants affecting rural communities, through asynchronous modules, case studies, and team-based learning. This innovative curriculum, which is flexible and inclusive of rural and metropolitan students, represents a strategic model for promoting rural healthcare careers, addressing workforce shortages, and ensuring equitable health outcomes for underserved communities. [ABSTRACT FROM AUTHOR]

Background: Women and people diagnosed with diabetes in pregnancy, are recommended to have frequent monitoring and careful management for optimal pregnancy outcomes. This health care management should be supported by a multidisciplinary healthcare team. For individuals living in rural areas, there are increased barriers to healthcare access, with subsequent worse health outcomes compared to those in metropolitan regions. Despite this, there remains a lack of research into the experiences of healthcare delivery for rural women and people with diabetes in pregnancy. Methods: Survey invitations were sent via the National Diabetes Services Scheme email list. The survey included multiple choice and open-ended questions. Responses from the open-ended question asking participants the changes they would want made to their care delivery were interpreted using qualitative content analysis. Responses were separated into metropolitan and rural categories using the Modified Monash Model criteria. Results: There were 668 survey responses, with 409 responding to the open-ended qualitative survey question/s. 71.6% of respondents were metropolitan and 27.6% lived rurally. A total of 31 codes were established from the open-ended responses, with the five overarching themes of 'quality of care', 'practice & communication', 'individual's experience', 'access' and 'burden of care' identified. The most frequently occurring codes irrespective of location included education or information (n = 45), frequency and timeliness of care (n = 42), no changes (n = 42) and improved health professional communication (n = 40). Local care options was the only code with more rural quotes compared to metropolitan. Conclusions: The most frequently occurring codes had strong representation from metropolitan and rural respondents, indicating that those with previous diabetes in pregnancy had similar priorities for changes in their healthcare delivery regardless of location. Rural respondents identifying local care options as a priority for change is likely indicative of the rural healthcare landscape with limited access to care options. Recommendations from this study supported by previous research include focusing on improving health professional communication both with women and people with diabetes in pregnancy and with other relevant professionals. Recommendations for rural locations should focus on improving local care options whilst considering resource limitation, such as telehealth clinics. [ABSTRACT FROM AUTHOR]

Air pollution is a pervasive environmental health hazard with the potential to worsen respiratory health outcomes, including asthma exacerbations. The impact of PM2.5 on asthma exacerbations among rural populations is not well understood. Our analysis used a retrospective, time-stratified, case-crossover study design to examine the relationship be- tween PM2.5 and asthma exacerbations. We included asthma exacerbations that occurred January 1, 2019--June 30, 2022, among residents of seven rural counties in Wisconsin with a PM2.5 air monitor. We also used PM2.5 data collected by the Wisconsin Department of Natural Resources and weather data available from the National Oceanic and Atmospheric Administration (NOAA). Further, we used conditional logistic regression to assess the association between asthma exacerbations and lagged PM2.5 levels, adjusting for maximum daily temperature. We found PM2.5 levels (µg/m3) 2 days prior to exacerbation were significantly associated with asthma exacerbations (hazard ratio 1.184; 95% confidence interval [1.051, 1.344]). Our study demonstrated an increased hazard of asthma exacerbations with higher levels of PM2.5 in rural populations. These findings highlight the need for further research and efforts to mitigate the effects of air pollution in rural areas. [ABSTRACT FROM AUTHOR]

Background: Cardiometabolic multimorbidity (CMM), characterized by the coexistence of diabetes, hypertension, and cardiovascular disease, poses a major health challenge in India, particularly in rural areas with limited healthcare resources. Lifestyle interventions can manage cardiometabolic risk factors, yet adherence remains suboptimal. Mobile health (mHealth) interventions offer a scalable approach for managing CMM by promoting behaviour change and medication adherence. We will develop and evaluate the MultiLife intervention, a mHealth-based lifestyle toolkit aimed at improving CMM management among individuals receiving primary care in Eastern India in the year 2025. Methods: This study is a two-arm, cluster-randomized controlled trial with a hybrid Type 1 design involving 840 participants across 18 primary health centres in Odisha and Jharkhand. Using the Health Belief Model as a conceptual framework, the MultiLife intervention will deliver daily digital reminders, weekly health education broadcasts, and ongoing primary care support in the intervention arm, while the control group will receive the standard ongoing primary care support care. The trained healthcare workers will recruit 50 CMM patients, with a 6-month intervention period, during routine visits in each cluster. Primary outcomes include changes in HbA1c from baseline (T0) to end-line (T6). Secondary outcomes include blood pressure, body mass index, physical activity, and dietary habits. Qualitative assessments will explore intervention barriers and facilitators. Implementation outcomes, assessed through the RE-AIM QuEST framework, will evaluate MultiFrame’s acceptability, adoption, fidelity, and maintenance. A random-effects regression model will be used for difference-in-difference analysis, adjusting for covariates and within-cluster correlations. Discussion: The MultiLife trial may provide valuable insights into how mHealth-enabled primary care can enhance patient engagement, adherence, and cardiovascular risk reduction in resource-constrained settings. By integrating patient perspectives, this study could inform scalable digital health strategies for comprehensive CMM management, providing a model for future interventions in similar contexts. Trial registration: CTRI.nic.in, CTRI/2024/10/074559, Registered on 1 October 2024. [ABSTRACT FROM AUTHOR]

Background: Place matters for health. In Texas, growing rural populations face a variety of structural, social, and economic disparities that position them for potentially worse health outcomes. The current study contributes to understanding rural health disparities in a state-specific context. Methods: Using 2023 County Health Rankings data from the University of Wisconsin Population Health Institute, the study analyzes rural/non-rural county differences in Texas across six composite indexed domains of health outcomes (length of life, quality of life) and health factors (health behavior, clinical care, socioeconomic factors, physical environment) with a chi-square test of significance and logistic regression. Results: Quartile ranking distributions of the six domains differed between rural and non-rural counties. Rural Texas counties were significantly more likely to fall into the bottom quartile(s) in the domains of length of life and clinical care and less likely to fall into the bottom quartile(s) in the domains of quality of life and physical environment. No differences were found in the domains of health behavior and socioeconomic factors. Findings regarding disparities in length of life and clinical care align with other studies examining disease prevalence and the unavailability of many health services in rural Texas. The lack of significant differences in other domains may relate to indicators that are not present in the dataset, given studies that find disparities relating to other underlying factors. Conclusions: Texas County Health Rankings data show differences in health outcomes and factors between rural and non-rural counties. Limitations of findings relate to the study's cross-sectional design and parameters of the secondary data source. Ultimately, results can help state health stakeholders, especially those in community or operational contexts with limited resources or access to more detailed health statistics, to use the CHR dataset to consider more relevant local interventions to address rural health disparities. [ABSTRACT FROM AUTHOR]

Background: Malnutrition, wasting, and obesity among children under 6 years old pose a serious global health concern, increasing the risk of various infectious and non-infectious diseases. Therefore, regular monitoring of these conditions is crucial. This study aimed to evaluate the prevalence of malnutrition in children under 6 years of age from 2018 to 2023. Method: This cross-sectional study was conducted on children under 6 years old who were referred to the urban and rural health centres in south Iran for routine health care. The researchers extracted the data from the health electronic records (SIB system) from 2018 to 2023. Results: This study showed the average prevalence of overweight and obesity is 20%, underweight and severe underweight is 4.9%, wasting and severe wasting is 7.4%, and stunted and severe shortness is 3.8%, 2018–2023. The average annual percentage change of severe wasting was 8.9% (95% CI 0.1% to 18.6%), underweight and severely underweight 5.7% (1.4–10.3) during the study years. The decreasing trend of stunted, particularly severe stunted, − 1.1% (− 0.7–5.2), the probability of overweight − 1.6% (95% CI − 4.7–1.5), and obesity − 1.1% (95% CI − 7–5.2) was seen. Conclusion: This study revealed a higher prevalence of overweight and obesity than previously reported, although the annual percentage change remained relatively stable. In contrast, a significant increase in underweight and wasting was observed over the past 5 years. Consequently, healthcare managers and policymakers should prioritize interventions to address these trends. Key messages: There was a significant increase in the prevalence of underweight and wasting in the south of Iran from 2018 to 2023 Although the prevalence of overweight and obesity in the present study was higher than in other studies, it was almost constant from 2018 to 2023 The managers and health policymakers must pay more attention and have a few interventions to prevent undernutrition in children under 6 years [ABSTRACT FROM AUTHOR]

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Background: Non-communicable diseases (NCDs) are the leading cause of global mortality. The WHO projects a rise in NCD-related deaths from 36 million in 2018 to 55 million by 2030, with developing countries being the most affected. Effective community-based primary health care (PHC) can reduce the burden of chronic diseases of lifestyle (CDLs). This study aimed to develop a risk assessment and health promotion framework to strengthen CDL prevention and control in Free State (FS) communities in South Africa. Methods: A convergent mixed-method design was used. Quantitative analysis identified CDL risk factors in rural and urban FS settings, while qualitative focus group discussions explored participants' knowledge of CDLs and their experiences with program implementation. Results: Key findings highlighted differences in risk profiles, CDL training needs for PHC teams, patient education gaps, and curriculum development. Step 1 of the framework development identified differences and similarities in the CDL risk profiles of the study populations. Step 2 identified CDL training needs for PHC teams, patient educational needs, and CDL curriculum development needs. Step 3 revealed three main barriers: resource constraints, patient non-compliance, and the lack of supporting healthcare services. In Step 4, the six focus areas identified (steps 1–3) were used to develop strategies for implementing a tailored, community-based, patient-centred approach. Conclusions: The results provide valuable insights for improving PHC responses in resource-limited settings. [ABSTRACT FROM AUTHOR]

Objective Study Setting and Design Data Sources and Analytic Sample Principal Findings Conclusions To determine whether rural hospital closures affected hospital and post‐acute care (PAC) use and outcomes.Using a staggered difference‐in‐differences design, we evaluated associations between 32 rural hospital closures and changes in county‐level: (1) travel distances to and lengths of stay at hospitals; (2) functional limitations at and time from hospital discharge to start of PAC episode; (3) 30‐day readmissions and mortality and hospitalizations for a fall‐related injury; and (4) population‐level hospitalization and death rates.100% Medicare claims and home health and skilled nursing facility clinical data to identify approximately 3 million discharges for older fee‐for‐service Medicare beneficiaries.We found that hospitals that closed compared to those remaining open served more minoritized, lower‐income populations, including more Medicaid and fewer commercial patients, and had lower profit margins. Following a closure, quarterly hospitalization rates (111.6 quarterly hospitalizations per 10,000 older adults; 95% CI: 53.4, 170.9) and average hospital lengths of stay increased (0.34 days; 95% CI: 0.13, 0.56 days). We observed no change in the average distance between patients' residential ZIP code and the hospital used (0.29 miles; 95% CI: −1.06, 1.64 miles); average number of standardized ADL limitations at PAC (0.08 SDs from the pre‐closure average; 95% CI: −0.12, 0.28 SDs); or PAC time to start (0.02 days; 95% CI: −1.2, 1.2 days). Among more isolated hospitals, closures were associated with an increase in the likelihood of readmission (0.10 percentage‐points; 95% CI: 0.00, 0.19).Closures were not associated with notably worsened health care access, function, or health, potentially because closures triggered care delivery adjustments involving increased numbers of patients seeking out higher quality care. [ABSTRACT FROM AUTHOR]

China's primary healthcare (PHC) system, together with rural healthcare services, remains the Achilles' heel in the national healthcare system. Healthcare workers, specifically village doctors, are an integral part of the healthcare system. Using the two-stage data envelopment analysis (DEA) and Tobit regression analysis, this study aims to investigate the efficiency of healthcare expenditures on medical resources and services in China, as well as determine how different types of healthcare work influence efficiency. Compared with other types of healthcare workers, village doctors exerted a prominent impact on provincial and rural efficiency at all stages and played a key role in augmenting the efficiency of healthcare expenditures on health outcomes. Besides, township health centers (THCs) and village clinics (VCs) faced administrative overstaffing, mainly involving pharmacists, other nonmedical technologists, and health administrators, which adversely affected the efficiency of healthcare expenditures. This study suggests that the higher the proportion of these non-village doctor positions (e.g., pharmacists, health administrators, and nonmedical technologists) in THCs and VCs, the lower the efficiency of China's PHC system. Overall, the priority should be enhancing the training and remuneration of village doctors and other healthcare workers in rural areas to further enhance their performance and increase the overall efficiency of China's healthcare system. [ABSTRACT FROM AUTHOR]

Background: Rural areas are increasingly moving back into the focus of social research, especially in the context of health care. As the shortage of general practitioners (GP) in rural areas is a significant challenge in Germany, there are several programs to counteract underuse effectively, acutely, and sustainably. One of those programs is 'Beste Landpartie Allgemeinmedizin' (BeLA), which was developed to strengthen primary care in rural areas and to sustainably promote young doctors to work as general practitioners in rural regions through didactical and financial support. The program includes an accompanying qualitative study exploring the motivational structures of medical students from a sociological perspective. For this study, the nexus of working in rural areas from the perspective of medical students with different forms of rural experiences was of interest. Methods: Qualitative interviews have been conducted at regular intervals on an ongoing basis since 2020 to investigate motivational retention effects during the program. The current 33 interviews were analysed using the sociological conceptual framework of spatial methods. Results: The images and experiences of working in rural areas condition medical education in various ways. In addition to general images of living and working in rural areas in a biographical dimension, the idea of working as a GP in rural areas includes images of specific medical competencies and is conditioned by different medical tasks. From such a perspective, the images and attributions of working in primary care in a rural region demonstrate particularities, challenges, and the potential attractiveness of working in rural regions. Discussion: The images and experiences of rural areas condition medical education in various ways and shape the expectations and the decision-making of possibly working in rural areas. The particularities, opportunities, and challenges of working in rural areas, which relate to both professional aspects and social life, are a major factor in the attractiveness of a potential rural practice. Didactical and educational curricula need to adapt the various attributions of working in rural areas. [ABSTRACT FROM AUTHOR]

In Liberia, children are exposed to multiple forms of adversity which can negatively impact their health and development. Research is needed to examine the feasibility and benefits of integrated interventions that can be incorporated into existing health delivery programs to simultaneously address low responsive stimulation, undernutrition, and infection. This study assessed the feasibility of an integrated intervention promoting psychosocial stimulation and improved child feeding by the provision of eggs and fish. The integrated intervention was incorporated into an existing government health program. Thirty female caregiver-child dyads were randomly selected from two rural communities in Liberia. Participants received fortnightly group parenting sessions and weekly eggs and fish designated for child consumption, for four weeks. Trained community health workers delivered the intervention. Assessments were conducted before and after the intervention using quantitative surveys and qualitative interviews. At baseline, we examined the home environment, caregiver-child interactions, diet, and infection control practices. At endline, we assessed the feasibility of the intervention. Descriptive analyses were conducted with quantitative data. Qualitative data were analyzed using conventional content analysis. Baseline findings indicated uncommon responsive parenting, inadequate early learning opportunities, high food insecurity, and high child morbidity. Mixed methods indicators of feasibility, including acceptability, adoption, and fidelity were high. Qualitative data from this feasibility study informed several future modifications to the program, including engaging fathers, supplementing group sessions with home visits, and broadening facilitator eligibility. This integrated intervention is feasible and can be incorporated into existing health programs to support early child development. [ABSTRACT FROM AUTHOR]

Water is essential for human survival, economic growth, and environmental sustainability. However, rural South Africa faces ongoing challenges in delivering reliable and clean water due to infrastructural inadequacies, climate variability, and historical disparities. Addressing these water supply issues is critical for reducing poverty, improving health outcomes, and fostering sustainable development in rural areas. This study utilises a mixed-methods approach within a positivist framework, collecting data through document analysis, self-administered surveys, and structured interviews with various stakeholders across four rural settlements in the Joe Gqabi and Gert Sibande District Municipalities. The primary aims are to evaluate water accessibility and reliability, examine the impact of water scarcity on poverty, investigate the availability of water infrastructure, and assess the effects of water supply on health and education. Findings indicate that deficient water infrastructure and intermittent supply significantly disrupt daily life, educational access, and healthcare services. Health risks due to contaminated water were prevalent, leading to waterborne diseases. Socio-economic impacts included exacerbated poverty, with particular challenges for female students in maintaining menstrual hygiene due to inconsistent water availability. The study proposes a sustainability model that integrates indigenous practices, such as rainwater harvesting and groundwater recharge, with modern water management technologies. This model, customised to local needs, underscores the importance of increased investment, integrated planning, and enhanced capacity-building in rural water management. By combining traditional and modern approaches, this model aims to improve water reliability, promote health, and support economic resilience in rural settlements. [ABSTRACT FROM AUTHOR]

Objective: To use a practical approach to examining the use of Expert Recommendations for Implementing Change (ERIC) strategies by Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE‐AIM) dimensions for rural health innovations using annual reports on a diverse array of initiatives. Data Sources and Study Setting: The Veterans Affairs (VA) Office of Rural Health (ORH) funds initiatives designed to support the implementation and spread of innovations and evidence‐based programs and practices to improve the health of rural Veterans. This study draws on the annual evaluation reports submitted for fiscal years 2020–2022 from 30 of these enterprise‐wide initiatives (EWIs). Study Design: Content analysis was guided by the RE‐AIM framework conducted by the Center for the Evaluation of Enterprise‐Wide Initiatives (CEEWI), a Quality Enhancement Research Initiative (QUERI)‐ORH partnered evaluation initiative. Data Collection and Extraction Methods: CEEWI analysts conducted a content analysis of EWI annual evaluation reports submitted to ORH. Analysis included cataloguing reported implementation strategies by Reach, Adoption, Implementation, and Maintenance (RE‐AIM) dimensions (i.e., identifying strategies that were used to support each dimension) and labeling strategies using ERIC taxonomy. Descriptive statistics were conducted to summarize data. Principal Findings: A total of 875 implementation strategies were catalogued in 73 reports. Across these strategies, 66 unique ERIC strategies were reported. EWIs applied an average of 12 implementation strategies (range 3–22). The top three ERIC clusters across all 3 years were Develop stakeholder relationships (21%), Use evaluative/iterative strategies (20%), and Train/educate stakeholders (19%). Most strategies were reported within the Implementation dimension. Strategy use among EWIs meeting the rurality benchmark were also compared. Conclusions: Combining the dimensions from the RE‐AIM framework and the ERIC strategies allows for understanding the use of implementation strategies across each RE‐AIM dimension. This analysis will support ORH efforts to spread and sustain rural health innovations and evidence‐based programs and practices through targeted implementation strategies. [ABSTRACT FROM AUTHOR]

Objective: To describe a learning health care system research process designed to increase buprenorphine prescribing for the treatment of opioid use disorder (OUD) in rural primary care settings within U.S. Department of Veterans Affairs (VA) treatment facilities. Data Sources and Study Setting: Using national administrative data from the VA Corporate Data Warehouse, we identified six rural VA health care systems that had improved their rate of buprenorphine prescribing within primary care from 2015 to 2020 (positive deviants). We conducted qualitative interviews with leaders, clinicians, and staff involved in buprenorphine prescribing within primary care from these sites to inform the design of an implementation strategy. Study Design: Qualitative interviews to inform implementation strategy development. Data Collection/Extraction Methods: Interviews were audio‐recorded, transcribed verbatim, and coded by a primary coder and secondary reviewer. Analysis utilized a mixed inductive/deductive approach. To develop an implementation strategy, we matched clinical needs identified within interviews with resources and strategies participants had utilized to address these needs in their own sites. Principal Findings: Interview participants (n = 30) identified key clinical needs and strategies for implementing buprenorphine in rural, primary care settings. Common suggestions included the need for clinical mentorship or a consult service, buprenorphine training, and educational resources. Building upon interview findings and in partnership with a clinical team, we developed an implementation strategy composed of an engaging case‐based training, an audit and feedback process, and educational resources (e.g., Buprenorphine Frequently Asked Questions, Rural Care Model Infographic). Conclusions: We describe a learning health care system research process that leveraged national administrative data, health care provider interviews, and clinical partnership to develop an implementation strategy to encourage buprenorphine prescribing in rural primary care settings. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact on rural Veterans' access to social work services of a Department of Veterans Affairs (VA) national program to increase social work staffing, by Veterans' rurality, race, and complex care needs. Data Sources and Study Setting: Data obtained from VA Corporate Data Warehouse, including sites that participated in the social work program between October 1, 2016 and September 30, 2021. Study Design: The study outcome was monthly number of Veterans per 1000 individuals with 1+ social work encounters. We used difference‐in‐differences to estimate the program effect on urban, rural, and highly rural Veterans. Among rural and highly rural Veterans, we stratified by race (American Indian or Alaskan Native, Asian, Black, Native Hawaiian or Other Pacific Islander, and White) and complex care needs (homelessness, high hospitalization risk, and dementia). Data Collection: We defined a cohort of 740,669 Veterans (32,434,001 monthly observations) who received primary care at a participating site. Principal Findings: Average monthly social work use was 8.7 Veterans per 1000 individuals. The program increased access by 49% (4.3 per 1000; 95% confidence interval, 2.2–6.3). Rural Veterans' social work access increased by 57% (5.0; 3.6–6.3). Among rural/highly rural Veterans, the program increased social work access for those with high hospitalization risk by 63% (24.5; 18.2–30.9), and for Veterans experiencing homelessness, 35% (13.4; 5.2–21.7). By race, the program increased access for Black Veterans by 53% (6.1; 2.1–10.2) and for Asian Veterans by 82% (5.1; 2.2–7.9). Conclusions: At rural VA primary care sites with social work staffing below recommended levels, Black and Asian Veterans and those experiencing homelessness and high hospitalization risk may have unmet needs warranting social work services. [ABSTRACT FROM AUTHOR]

The National Medical Commission (NMC) of India has introduced the Family Adoption Program (FAP) as a key initiative within the Competency-Based Medical Education (CBME) framework. FAP is designed to reshape medical education by deeply embedding students within communities, providing a platform for experiential learning that enhances their understanding of healthcare challenges beyond the clinical setting. Under the program, medical students adopt families in rural or underserved areas and work with them over an extended period, addressing health needs and fostering a holistic, socially responsive approach to care. This engagement allows students to understand the multifaceted determinants of health—such as social, economic, cultural, and environmental factors—that influence well-being and disease. Through direct interaction with families, students develop a community-centred approach to healthcare delivery, fostering continuity of care and empowering communities in managing their own health. This paper explores how FAP integrates community engagement into medical education, driving both student learning and community health outcomes. It outlines the theoretical underpinnings and practical implementation strategies of FAP, offering a roadmap for medical colleges to successfully integrate this initiative into their curricula. The paper highlights best practices and innovative approaches from institutions, emphasizing the need for institutional ownership, interdisciplinary collaboration, and partnerships with local communities to ensure long-term success. Additionally, it provides insights for scaling FAP nationally, positioning it as a transformative step towards cultivating compassionate, community-oriented healthcare professionals. By fostering deeper connections between medical students and communities, FAP has the potential to improve health equity and transform health care across India. [ABSTRACT FROM AUTHOR]