Journal of Rural Health最新文献

Purpose: Many rural areas lack brick-and-mortar HIV prevention resources despite the increasing rates of HIV. Although online HIV pre-exposure prophylaxis (PrEP) programs can potentially increase uptake among rural sexual minority men (SMM), their attitudes and preferences regarding telehealth-based PrEP (telePrEP) programming are uncertain. This qualitative study examined rural SMM's perceived risks and benefits of participating in a hypothetical telePrEP program.

Methods: Twenty rural SMM living in Texas completed a semi-structured online videoconferencing interview between April 12 and June 14, 2023. Data were analyzed with reflexive thematic analysis.

Findings: Four themes were constructed: (1) telePrEP interventions increase accessibility but completely online services might be inadequate; (2) telePrEP and mail-order interventions are convenient but face challenges; (3) telePrEP interventions need to address confidentiality and privacy within the context of the sociopolitical climate; and (4) telePrEP interventions need to address trustworthiness and transparency.

Conclusions: Overall, our results indicate that rural SMM perceive telePrEP interventions that provide at-home and telehealth PrEP, HIV testing, and HIV care services as beneficial. However, overall utility and acceptability depend on perceptions of privacy, confidentiality, trustworthiness, and transparency. Given the HIV prevention and treatment service deserts in which many rural SMM live, telePrEP interventions must purposefully demonstrate how their operations and data will remain safe and secure. Further work should explore contextual or situational factors that influence the willingness and acceptability of rural SMM to participate in online HIV prevention intervention research studies.

Purpose: In Australia, there is limited research regarding the effect of rurality on health care utilization using longitudinal data.

Methods: We analyzed data from four annual waves (2009, 2013, 2017, and 2021) of the longitudinal Household, Income and Labour Dynamics in Australia (HILDA) Survey to examine changes in the health care utilization over time among urban and rural residents. Poisson regression models estimated adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CIs) for rural versus urban residents, accounting for a range of health-related and sociodemographic characteristics. Health care utilization was measured using four key indicators: visits to family doctor or another general practitioner (GP visits from hereon), hospital admissions, total nights' stay in the hospital, and prescribed medications taken on a regular basis.

Results: The aIRR for GP visits among rural versus urban Australian residents increased over time, from 0.89 (95% CI: 0.82 to 0.97) in 2009 to 0.96 (95% CI: 0.89 to 1.04) in 2021 although not consistently increased in a statistically significant manner. While there were no consistent temporal patterns, our analysis found that rural residents experienced higher number of hospital admissions (aIRR, 1.12 to 1.15) and number of nights in the hospital in the last 12 months (aIRR, 1.18 to 1.25) compared to urban residents. Moreover, rurality had little to no effect on the number of prescribed medications taken on a regualar basis in the 12 months preceding the HILDA Surveys in 2013, 2017, and 2021.

Conclusions: This study found that GP visits were less frequent among rural residents compared to metropolitan residents in 2009, indicating health care access disparities between rural and urban areas in Australia. However, the differences in GP visits between rural and urban areas were less pronounced  from 2013 to 2021.

Purpose: To create a model that predicts future financial distress among rural hospitals.

Methods: The sample included 14,116 yearly observations of 2311 rural hospitals recorded between 2013 and 2019. We randomly separated all sampled hospitals into a training set and test set at the start of our analysis. We used hospital financial performance, government reimbursement, organizational traits, and market characteristics to predict a given hospital's risk of experiencing one of three financial distress outcomes-negative cash flow margin, negative equity, or closure.

Findings: The model's area under the receiver operating characteristic curve (AUC) equaled 0.87 within the test set, indicating good predictive ability. We classified 30.55% of the observations in our sample as lowest risk of experiencing financial distress over the next 2 years. In comparison, we classified 32.52% of observations as mid-lowest risk of distress, 26.40% of observations as mid-highest risk, and 10.52% of observations as highest risk. Among test set observations classified as lowest-risk, 5.78% experienced negative cash flow margin within 2 years, 1.50% experienced negative equity within 2 years, and zero observations experienced closure within 2 years. Within the highest-risk group, 61.57% of observations experienced negative cash flow margin, 43.02% experienced negative equity, and 3.33% experienced closure.

Conclusions: Given the ongoing challenges and consequences of rural hospital unprofitability, there is a clear need for accurate assessments of financial distress risk. The financial distress model can be used by researchers, policymakers, and rural health advocates as a screening tool to identify at-risk rural hospitals for closer monitoring.

Purpose: To assess rural-urban and health professional shortage area (HPSA)-related influences on the characteristics of melanoma in North Carolina.

Methods: We conducted a single-center retrospective cohort study of patients living in North Carolina with an available pathology report for invasive cutaneous melanoma seen in the Duke University Health System from 01/01/2014 to 12/31/2020. Multivariable logistic regression models were employed to compare patient and tumor characteristics between rural versus urban county residence as well between melanoma thicknesses dichotomized into thin (≤1.0 mm) and thicker (>1.0 mm) tumors.

Findings: The cohort included 807 patients, and rural patients accounted for 177 (21.9%) of invasive cutaneous melanomas. Rural patients had significantly higher odds of having thicker tumors than urban patients (odds ratio [OR] = 1.78, 95% confidence interval [CI]: 1.17-2.71; P = .008). Rural patients were significantly more likely to be female (OR = 1.59, 95% CI: 1.10-2.28; P = .013) and located in a population-based (OR = 2.66, 95% CI: 1.84-3.84; P<.001) or geographic-based (OR = 8.21, 95% CI: 3.33-20.22; P<.001) HPSA. Living in a medium- or high-shortage population-based HPSA was associated with higher odds of thicker tumors (OR = 2.65, 95% CI: 1.85-3.80; P<.001).

Conclusions: Patients living in rural North Carolina counties were more likely than those in urban counties to be diagnosed with melanomas >1.0 mm in thickness, a clinically significant difference with important prognostic implications. Interventions at the county- and state-level to address this disparity may include improving access to skin cancer screening and teledermatology programs, increasing partnerships with primary care providers, and targeting interventions to counties with health professional shortages.

Background: Understanding the mix of video versus audio telehealth modality is critical to informing care for low-income safety net clinic patients. Our study examined whether telehealth modality and continued use of telehealth varied by rurality and whether that changed over time.

Methods: Encounters from adults in the OCHIN national network of primary care safety net clinics were identified by encounter type (in-person vs telehealth) and telehealth modality (video vs audio) from 4/1/2021 to 3/31/2023. Our main outcome was an interaction between patient rurality (defined using Rural Urban Commuting Area codes) and time. Linear probability models with clinic fixed effects were used to estimate predicted probabilities.

Results: The predicted probability of a telehealth visit decreased from 37.9% to 24.7% among urban patients (P <.001) and remained stable (29.5%-29.8%; P = .82) among patients in small rural areas. By March 2023, telehealth use among patients in small rural areas was 5.1 percentage points higher than among urban patients (P = .02). The predicted probability of an audio-only visit ranged from 63.5% to 70.5% for patients across all levels of rurality, but no significant differences by rurality or time were found.

Conclusions: Safety net clinic patients were more likely to use audio-only than video telehealth visits. Telehealth in urban and large rural areas decreased since the first year of the pandemic. By the end of the study, patients in small rural communities used significantly more telehealth than urban patients. Elimination of reimbursement for audio telehealth visits may exacerbate existing health care inequities.

Aims: Rural hospitals in the United States often rely on nonphysician providers such as advanced practice nurses to care for their patients. One important role that is served by advanced practice nurses is that of anesthesia provider (certified registered nurse anesthetist or CRNA). In 2001, Centers for Medicare & Medicaid Services (CMS) passed an opt-out law affording state governors the right to loosen physician supervision requirements on CRNAs in their respective states, thus potentially improving access in targeted areas. Since then, 24 states have adopted these opt-out provisions. We aim to understand the extent to which the CMS opt-out law has resulted in increased CRNA service provision in hospitals, especially in rural areas.

Design: The study used a longitudinal design. We compiled 2010-2021 American Hospital Association data, which includes 4,464 unique U.S. hospitals observed an average of 8 times annually (35,863 total hospital-year observations).

Methods: We model CRNA services provision at the hospital level using longitudinal mixed effects generalized linear models that incorporate state, county, and hospital control variables.

Results: Using descriptive statistics and mixed effects generalized linear models, we discovered that adopting opt-out provisions does not universally result in increased CRNA service provision in U.S. hospitals. Notably, opt-out provisions do not improve access in rural counties. However, in supplemental analysis, we discover some of the conditions under which the likelihood of CRNA service provision is influenced.

Conclusions: Hospitals often utilize CRNAs to staff their hospitals. However, many hospitals use both CRNAs and physician anesthesiologists; this can be a potential source of contention and confusion, given the lack of uniformity in the scope of practice policies. We offer some suggestions with regard to the effects of state interventions into the field, and how they might impact this dispute. Lastly, policymakers should consider additional measures to address rural access limitations, as the opt-out policy does not seem to be working as intended.

Objective: To investigate the ways in which food insecurity, food acquisition behaviors, and perceived and objective food access influence fruit and vegetable intakes among rural Georgians.

Design: A population-based survey was merged with USDA's Food Access Research Atlas, and multilevel modeling was used to determine individual-level (eg, food insecurity, food acquisition behaviors, perceived access) and environmental-level (eg, census tract food access) predictors of fruit and vegetable intakes.

Setting: Twenty-four rural census tracts in 6 counties in Georgia, USA.

Participants: One thousand four hundred and seventy-four adults.

Results: Residing in a low food access census tract was not associated with fruit or vegetable intake. Food insecurity had negative effects on both fruit and vegetable intakes. Perceived access to fresh fruits and vegetables was positively associated with fruit intake, and obtaining fresh fruits and vegetables from community or home gardens was positively associated with both fruit and vegetable intakes.

Conclusions: Findings are unique from previous research on census tract-level fruit and vegetable determinants, underscoring the need for a better understanding of influences on fruit and vegetable intakes among rural populations. Interventions to increase fruit and vegetable consumption in rural areas should prioritize food security.

Purpose: To understand gender differences in factors affecting rural health care workforce to inform the development of effective policies and recruitment strategies to address rural health care workforce shortages.

Methods: A cross-sectional survey of health care professionals (including Advanced practice registered nurses (APRNs), physicians, physician assistants (PAs), and registered nurses (RNs)) in Minnesota was administered by the Minnesota Department of Health from October 18, 2021, to July 25, 2022, during their professional license renewal. The main outcome was whether or not the respondent was practicing in a rural area. The effects of factors associated with rural practice were estimated using binary logistic regression models, and subsequently subgroup analysis was conducted by gender across the four health care professions.

Findings: Results show that although there were significant gender differences in some factors (growing up in a rural area and family considerations were more likely to influence women's decisions than men's, whereas men were more likely to be influenced by the prospect of having autonomy and broad scope of practice than women), these differences became insignificant when the four health care professionals were analyzed separately suggesting that overall gender differences observed were almost entirely explained by profession differences.

Conclusions: Gender differences do not significantly influence the factors impacting rural practice. However, being raised in a rural environment emerges as the most influential predictor of rural practice underscoring the importance of involving rural residents of all genders in health care practice.

Purpose: Over 75% of Americans have legal access to medical cannabis, though physical access is not uniform and can be difficult for rural residents. Additionally, substantial stigma remains in using medical cannabis, particularly within the health care system. This article argues that rural Americans may be particularly affected by such stigma and may thus be more likely to not report cannabis use to health care providers.

Methods: Data were obtained from 1,045 adult Pennsylvanians using a self-administered web panel omnibus survey. Rurality was determined by overlaying Zip Code Tabulation Areas with urban areas, as defined by the U.S. Census Bureau. Primary outcomes were prior use of cannabidiol (CBD) or marijuana and reporting of such use to medical professionals. Covariates utilized in logistic regressions included rurality, gender, age, race/ethnicity, political affiliation, political ideology, and veteran status.

Findings: Living in an urban area was positively associated with disclosure of marijuana use to health care providers as compared to those in rural areas, although there were no differences found in CBD disclosure.

Conclusions: Stigma surrounding marijuana usage may have a disproportionate impact on health outcomes for rural residents who use marijuana. Nonreporting prevents effective holistic medical care and can result in negative drug interactions and other side effects.

Purpose: Estimate health-quality-adjusted life expectancy (QALE) for Americans nearing retirement age and assess rural-urban disparities in QALE.

Methods: We used a dynamic microsimulation model based on Health and Retirement Study data to estimate the quantity and health quality of expected future life years for rural and urban Americans ages 59-60 in 2014-2020.

Findings: Cohort life expectancy at age 60 (LE) for urban and rural men was 22.9 and 20.9, respectively; for urban and rural women, LE was 25.6 and 25.0, respectively. Adjusting future life years to quality-adjusted life years, QALE was 17.5 versus 15.7 for urban versus rural men, and 19.3 versus 18.7 for women. Compared to a cohort in 1994-2000, the urban-rural QALE gap in 2014-2020 grew substantially for men; changes for women were smaller. Average QALE masked heterogeneity by race/ethnicity, education, and Census region. Counterfactual scenarios suggested eliminating smoking and managing obesity and prevalent heart conditions would be particularly beneficial for increasing rural QALE and reducing the urban-rural gap.

Conclusions: Expected health quality, in addition to longevity, is an important factor when assessing rural disparities in older Americans' future life outcomes. Current chronic disease disparities are expected to translate to a widening urban-rural gap in QALE, particularly for men. Interventions earlier in life may be needed to fully address disparities in QALE at older ages.