A scoping review of the barriers and facilitators to accessing and utilising mental health services across regional, rural, and remote Australia

BACKGROUND

Inadequate healthcare access and utilisation are implicated in the mental health burden experienced by those living in regional, rural, and remote Australia. Facilitators that better enable access and utilisation are also reported in the literature. To date, a synthesis on both the barriers and facilitators to accessing and utilising mental health services within the rural Australian context has not been undertaken. This scoping review aims to (1) synthesise the barriers and facilitators to accessing and utilising mental health services in regional, rural, and remote Australia, as identified using the Modified Monash Model; and (2) better understand the relationship between barriers and facilitators and their geographical context.

METHODS

A systematic search of Medline Complete, EMBASE, PsycINFO, Scopus, and CINAHL was undertaken to identify peer-reviewed literature. Grey literature was collated from relevant websites. Study characteristics, including barriers and facilitators, and location were extracted. A descriptive synthesis of results was conducted.

RESULTS

Fifty-three articles were included in this scoping review. Prominent barriers to access and utilisation included: limited resources; system complexity and navigation; attitudinal and social matters; technological limitations; distance to services; insufficient culturally-sensitive practice; and lack of awareness. Facilitators included person-centred and collaborative care; technological facilitation; environment and ease of access; community supports; mental health literacy and culturally-sensitive practice. The variability of the included studies precluded the geographical analysis from being completed.

CONCLUSION

Both healthcare providers and service users considered a number of barriers and facilitators to mental health service access and utilisation in the regional, rural, and remote Australian context. Barriers and facilitators should be considered when re-designing services, particularly in light of the findings and recommendations from the Royal Commission into Victoria's Mental Health System, which may be relevant to other areas of Australia. Additional research generated from rural Australia is needed to better understand the geographical context in which specific barriers and facilitators occur.

Adverse health outcomes among rural prostate cancer survivors: A population-based study

INTRODUCTION

Rural cancer survivors experience considerable health disparities compared to urban cancer survivors for cancer treatment and survival. The objective of our study was to investigate the risk of developing diseases for rural compared to urban prostate cancer survivors in Utah.

METHODS

We identified a cohort of 3575 rural prostate cancer survivors and 17,778 urban prostate cancer survivors from the Utah Cancer Registry. The Fine-Gray subdistribution hazards model was used to estimate hazard ratios and 95 % confidence intervals for diseases in major body systems among rural compared to urban prostate cancer survivors at > 1-5 years and > 5 years after prostate cancer diagnosis.

RESULTS

Rural residence was associated with an increased risk of diseases of the respiratory system at > 5 years (HR: 1.16, 95 % CI: 1.01-1.32) after cancer diagnosis compared to urban residence among prostate cancer survivors in Utah. Decreased risks were observed in infectious and parasitic diseases, diseases of the blood and blood-forming organs, diseases of the nervous system and sense organs, and diseases of the skin and subcutaneous tissue for rural prostate cancer survivors between 1 and 5 years after cancer diagnosis.

CONCLUSIONS

Rural prostate cancer survivors in Utah were somewhat healthier compared to urban prostate cancer survivors. Further studies are needed to confirm whether these associations are also supported for rural prostate cancer survivors in other regions of the U.S.

Communicating about the social determinants of health: development of a local brand

BACKGROUND

Successful comprehensive population-based approaches to chronic disease prevention leverage mass media to amplify messages and support a culture of health. We report on a community-engaged formative evaluation to segment audiences and identify major themes to guide campaign message development for a transformative health communication campaign.

METHODS

Four key phases of campaign development: (I) Formative evaluation to identify priorities, guiding themes, and audience segments (interviews/focus groups with residents, N = 85; representatives of community-based partner organizations, N = 10); (II) Brand development (focus groups and closed-ended surveys; N = 56); (III) Message testing approaches to verbal and visual appeals (N = 50 resident intercept interviews); (IV) Workshop (N = 26 participants representing 15 organizations).

RESULTS

Residents were engaged throughout campaign development and the resulting campaign materials, including the campaign name and visual aesthetic (logo, color schemes, overall look and feel) reflect the diversity of the community and were accepted and valued by diverse groups in the community. Campaign materials featuring photos of county residents were created in English, Spanish, and Hmong. Plain language messages on social determinants of health resonate with residents. The county was described as a sort of idyllic environment burdened by inequality and structural challenges. Residents demonstrated enthusiasm for the campaign and provided specific suggestions for content (education about disease risks, prevention, management; information about accessing resources; testimonials from similar people) and tone.

CONCLUSIONS

Communication to support a policy, systems, and environmental change approach to chronic disease prevention must carefully match messages with appropriate audiences. We discuss challenges in such messaging and effectiveness across multiple, diverse audiences.

It's Not Always Easy: Cancer Survivorship Care in Primary Care Settings

By 2040, an anticipated 26.1 million people with a history of cancer will be part of the healthcare system. The purpose of this study was to explore Missouri-based non-oncology clinicians' perspectives on caring for patients with a history of cancer to identify needs of rural-based clinicians to optimize their patients' survivorship care. Using an interpretive qualitative descriptive approach, we conducted semi-structured interviews with 17 non-oncology clinicians. We encouraged clinicians to discuss their approach to caring for patients with a history of cancer and invited them to talk about what might help them increase their knowledge of survivorship care best practices. Through interpretive qualitative descriptive analysis methods including first level coding and constant comparison, we found there is consensus that cancer survivorship care is important; however, training that now guides our clinicians occurred mostly during residency, if at all. Clinicians relied on previous patient encounters and oncology notes combined with their patients' personal account of treatment history to inform the best next steps. Clinicians expressed strong interest in having a simple protocol of their patient's treatment with prompts of known long-term cancer treatment-related effects and a patient-centric follow-up monitoring schedule (mandatory vs recommended vs optional). Clinicians expressed interest in educational opportunities about cancer care and ability for curbside consults with oncologists. They consistently noted the limited resources available in rural areas and that rural patients may have different preferences and approaches to cancer survivorship. There is a clear opportunity to improve non-oncology clinicians' knowledge of the needs of people with a history of cancer as well as their own knowledge base and self-efficacy, especially in rural settings.

Guideline-discordant inhaler regimens after COPD hospitalization: associations with rurality, drive time to care, and fragmented care - a United States cohort study

Background

Many patients receive guideline-discordant inhaler regimens after chronic obstructive pulmonary disease (COPD) hospitalization. Geography and fragmented care across multiple providers likely influence prescription of guideline-discordant inhaler regimens, but these have not been comprehensively studied. We assessed patient-level differences in guideline-discordant inhaler regimens by rurality, drive time to pulmonary specialty care, and fragmented care.

Methods

Retrospective cohort analysis using national Veterans Health Administration (VA) data among patients who received primary care and prescriptions from the VA. Patients hospitalized for COPD exacerbation between 2017 and 2020 were assessed for guideline-discordant inhaler regimens in the subsequent 3 months. Guideline-discordant inhaler regimens were defined as short-acting inhaler/s only, inhaled corticosteroid (ICS) monotherapy, long-acting beta-agonist (LABA) monotherapy, ICS + LABA, long-acting muscarinic antagonist (LAMA) monotherapy, or LAMA + ICS. Rural residence and drive time to the closest pulmonary specialty care were obtained from geocoded addresses. Fragmented care was defined as hospitalization outside the VA. We used multivariable logistic regression models to assess associations between rurality, drive time, fragmentated care, and guideline-discordant inhaler regimens. Models were adjusted for age, sex, race/ethnicity, Charlson Comorbidity Index, Area Deprivation Index, and region.

Findings

Of 33,785 patients, 16,398 (48.6%) received guideline-discordant inhaler regimens 3 months after hospitalization. Rural residents had higher odds of guideline-discordant inhalers regimens compared to their urban counterparts (adjusted odds ratio [aOR] 1.18 [95% CI: 1.12-1.23]). The odds of receiving guideline-discordant inhaler regimens increased with longer drive time to pulmonary specialty care (aOR 1.38 [95% CI: 1.30-1.46] for drive time >90 min compared to <30 min). Fragmented care was also associated with higher odds of guideline-discordant inhaler regimens (aOR 1.56 [95% CI: 1.48-1.63]).

Interpretation

Rurality, long drive time to care, and fragmented care were associated with greater prescription of guideline-discordant inhaler regimens after COPD hospitalization. These findings highlight the need to understand challenges in delivering evidence-based care.

Funding

NIHNCATS grants KL2TR002492 and UL1TR002494.

A population-based survey of self-reported delays in breast, cervical, colorectal and lung cancer screening

The early COVID-19 pandemic was associated with cessation of screening services, but the prevalence of ongoing delays in cancer screening into the third year of the pandemic are not well-characterized. In February/March 2022, a population-based survey assessed cancer needs in New Hampshire and Vermont. The associations between cancer screening delays (breast, cervical, colorectal or lung cancer) and social determinants of health, health care access, and cancer attitudes and beliefs were tested. Distributions and Rao-Scott chi-square tests were used for hypothesis testing and weighted to represent state populations. Of 1717 participants, 55% resided in rural areas, 96% identified as White race, 50% were women, 36% had high school or less education. Screening delays were reported for breast cancer (28%), cervical cancer (30%), colorectal cancer (24%), and lung cancer (30%). Delays were associated with having higher educational attainment (lung), urban living (colorectal), and having Medicaid insurance (breast, cervical). Low confidence in ability to obtain information about cancer was associated with screening delays across screening types. The most common reason for delay was the perception that the screening test was not urgent (31% breast, 30% cervical, 28% colorectal). Cost was the most common reason for delayed lung cancer screening (36%). COVID-19 was indicated as a delay reason in 15-29% of respondents; 12-20% reported health system capacity during the pandemic as a reason for delay, depending on screening type. Interventions that address sub-populations and reasons for screening delays are needed to mitigate the impact of the COVID-19 pandemic on cancer burden and mortality.

Implementation of a Cancer Education Program in Rural Counties with the Lowest HPV Vaccination Rates and Health Rankings

Background

Human papillomavirus (HPV) is the most common sexually transmitted infection (STI). To address STIs, one rural county public school district developed a series of Family Life Programs to educate pre-teens about pertinent health information. The Schooling Cancer Program (SCP) was developed in partnership with the local Cancer Research and Resource Center to raise awareness about cancer risk factors including HPV-related cancers and HPV prevention methods.

Methods

We collected a post-evaluation survey from students who attended a SCP session at one of the targeted middle schools. The SCP educated students about topics focusing on healthy lifestyles. The survey asked students' knowledge on the SCP topics, HPV knowledge, tobacco usage, and factors that reduced cancer development.

Results

87% agreed that tobacco products are associated with cancer, and 81% did not agree that E-cigarettes are scientifically proven to be safer than cigarettes. Although we do not have pre-evaluation data about these students' HPV knowledge, our evaluation survey shows that 80% of students correctly identified HPV as the most common STI, and 84% of students correctly identified the factors that decrease their risk of developing cancer.

Conclusion

Through this initiative, students learned essential health concepts and HPV-related risk factors.

Determinants of access to general practice in a shared care model for people living with HIV: a qualitive study of patients' perspectives in an Australian rural community

BACKGROUND

Improved management of human immunodeficiency virus (HIV) has resulted in improved life expectancy for people living with HIV and an ageing population with a significant comorbidity burden. Shared care models, involving the co-ordinated liaison between general practitioners and specialist physicians, have been advocated for in Australia to provide comprehensive care. People living with HIV in rural areas have reduced access to general practice and therefore shared care. This study explores the perspectives of people living with HIV on the barriers and enablers to accessing shared care in an Australian rural setting.

METHODS

In this qualitative study, semi-structured interviews were conducted with adults living with HIV who either resided in or accessed care in a rural area of Australia. Interviews were conducted via video conferencing, phone or face-to-face. Transcripts were imported into NVivo, coded and analysed in alignment with a conceptual framework of healthcare access defined by Levesque and colleagues.

RESULTS

Thirteen interviews were conducted in total. Participants' narratives demonstrated the substantial influence of accessibility to general practice on their ability to engage in effective shared care. Challenges included the perception that general practitioners would not provide additive value to participants' care, which restricted the ability to both seek and engage in the shared care model. Healthcare beliefs, expectations and experiences with stigma led participants to prioritise the perceived interpersonal qualities of specialist care above a shared care system. Access to shared care was facilitated by continuity of care in general practice but logistical factors such as affordability, transport and availability impacted the ability to access regular high-quality healthcare.

CONCLUSIONS

Navigating patient priorities and anticipated stigma in general practice within the resource limitations of rural healthcare were barriers to effective shared care. General practitioners' ability to build rapport and long-term relationships with participants was instrumental in the perception of valuable care. Strategies are required to secure continuity of care with interpersonally skilled general practitioners to ensure provision of quality primary care for people living with HIV, which can be supported by specialist physicians in a shared care model.

Engaging Community-Based Organizations to Address Barriers in Public Health Programs: Lessons Learned From COVID-19 Vaccine Acceptance Programs in Diverse Rural Communities

Factors such as geography, community hesitancy, the political landscape, and legislative efforts to limit public health authority have contributed to a disproportionate number of COVID-19 infections and deaths in US rural communities. Community-based organizations are trusted entities that provide social and educational services in the communities where they live and have proven to be effective public health partners in response to the COVID-19 pandemic. Recognizing the unique challenges faced by rural communities, coupled with higher rates of vaccine hesitancy, the CDC Foundation awarded grants to 21 community-based organizations serving rural communities in 7 Midwest states to support the equitable uptake and distribution of COVID-19 vaccines. In this case study, 2 grantees, the Missouri Center for Public Health Excellence and the Hmong American Center, provide case studies that document their experiences, challenges, and strategies for overcoming barriers during the implementation of COVID-19 vaccine acceptance projects in diverse rural communities. These case studies provide key lessons learned that can be applied to future public health emergency and nonemergency responses to ensure that all members of communities are served well and protected.

Rurality as a Risk Factor for Pulmonary Health Disparities

Rural populations experience significant pulmonary health disparities compared with urban populations. Patients in rural communities experience health determinants including high smoking prevalence, worse nutrition, lower educational attainment, specific occupational exposures, decreased health-care access, as well as unique cultural and political drivers of health. This article describes social determinants of pulmonary health relevant in rural communities, describes examples of existing pulmonary disparities in rural populations, and highlights health policies with potential to mitigate disparities.

System interventions to support rural access to maternity care: an analysis of the rural surgical obstetrical networks program

BACKGROUND

The Rural Surgical Obstetrical Networks (RSON) project was developed in response to the persistent attrition of rural maternity services across Canada over the past two decades. While other research has demonstrated the adverse health and psychosocial consequences of losing local maternity services, this paper explores the impact of a program designed to increase the sustainability of rural services themselves, through the funding of four "pillars": increased scope and volume, clinical coaching, continuous quality improvement (CQI) and remote presence technology.

METHODS

We conducted in-depth, qualitative research interviews with rural health care providers and administrators in eight rural communities across British Columbia to understand the impact of the RSON program on maternity services. Researchers used thematic analysis to generate common themes across the dataset and interpret findings.

FINDINGS

Participants articulated six themes regarding the sustainability of maternity care as actualized through the RSON project: safety and quality through quality improvement opportunities, improved access to care through increased surgical volume and OR backup, optimized team function through innovative models of care, improved infrastructure, local innovation surrounding workforce shortages, and locally tailored funding models.

CONCLUSION

Rural maternity sites benefited from the funding offered through the RSON pillars, as demonstrated by larger volumes of local deliveries, nearly unanimous positive accounts of the interventions by health care providers, and evidence of staffing stability during the study time frame. As such, the interventions provided through the Rural Surgical Obstetrical Networks project as well as study findings on the common themes of sustainable maternity care should be considered when planning core rural health services funding schemes.

Equity and extent of financial risk protection indicators during COVID-19 pandemic in rural part of Tamil Nadu, India

Catastrophic health expenditure [CHE] in India is on a rise. This situation would worsen even further when resources are disproportionately distributed across various socioeconomic classes. Hence, we conducted this study to determine the equity and extent of out-of-pocket [OOP] payments, Catastrophic health expenditure and impoverishment among rural households during COVID-19 pandemic in Tamil Nadu, India. A cross-sectional survey covering 2409 households was conducted during November 2021 across six districts in rural part of Tamil Nadu. Information on out-of-pocket payments, Catastrophic health expenditure (based on 40% capacity-to-pay [CTP] method) and impoverishment was obtained through World Health Organization standard criteria. Point estimates were reported as proportions with 95% Confidence Interval [CI]. Our results showed that the proportion of households with out-of-pocket payments on health and Catastrophic health expenditure in the month preceding the survey was 82.8% (95%CI: 81.2%-84.3%) and 26.9% (95%CI: 25.1%-28.7%) respectively. Nuclear (couple with dependent children only) and joint family type (extended family), presence of under-five children and lower socioeconomic status were significant determinants of Catastrophic health expenditure. The prevalence of impoverishment was 6.4% (95%CI: 5.4%-7.5%). To conclude, more than three fourth of the rural households in Tamil Nadu has out-of-pocket payments for health with one-fourth having Catastrophic health expenditure. Almost one in fourteen non-poor households faced impoverishment during the COVID-19 pandemic. This shows the disproportionate distribution of health expenses especially in the rural areas. Hence, appropriate financial risk protection measures should be taken in order to progress towards universal healthcare in our country.

The role of social cohesion in explaining rural/urban differences in healthcare access and health status among older adults in the mid-Atlantic United States

Social cohesion can influence health. It is higher among rural versus urban residents, but the burden of chronic disease is higher in rural communities. We examined the role of social cohesion in explaining rural/urban differences in healthcare access and health status. Rural (n = 1080) and urban (n = 1846) adults (ages 50+) from seven mid-Atlantic U.S. states completed an online, cross-sectional survey on social cohesion and health. We conducted bivariate and multivariable analyses to evaluate the relationships of rurality and social cohesion with healthcare access and health status. Rural participants had higher social cohesion scores than did urban participants (rural: mean = 61.7, standard error[SE] = 0.40; urban: mean = 60.6, SE = 0.35; adjusted beta = 1.45, SE = 0.54, p < .01). Higher social cohesion was associated with greater healthcare access: last-year check-up: adjusted odds ratio[aOR] = 1.25, 95% confidence interval[CI] = 1.17-1.33; having a personal provider: aOR = 1.11, 95% CI = 1.03-1.18; and being up-to-date with CRC screening: aOR = 1.17, 95% CI = 1.10-1.25. In addition, higher social cohesion was associated with improved health status: higher mental health scores (adjusted beta = 1.03, SE = 0.15, p < .001) and lower body mass index (BMI; beta = -0.26, SE = 0.10, p = .01). Compared to urban participants, rural participants were less likely to have a personal provider, had lower physical and mental health scores, and had higher BMI. Paradoxically, rural residents had higher social cohesion but generally poorer health outcomes than did urban residents, even though higher social cohesion is associated with better health. These findings have implications for research and policy to promote social cohesion and health, particularly for health promotion interventions to reduce disparities experienced by rural residents.

Implementing practice facilitation in research: how facilitators spend their time guiding practices to improve blood pressure control

BACKGROUND

Practice facilitators (PFs) coach practices through quality improvement (QI) initiatives aimed at enhancing patient outcomes and operational efficiencies. Practice facilitation is a dynamic intervention that, by design, is tailored to practices' unique needs and contexts. Little research has explored the amount of time PFs spend with practices on QI activities. This short report expands on previously published work that detailed a 12-month practice facilitation intervention as part of the Southeastern Collaboration to Improve Blood Pressure Control (SEC) trial, which focused on improving hypertension control among people living in rural settings in the southeastern USA. This report analyzes data on the time PFs spent to guide 32 primary care practices in implementing QI activities to support enhanced outcomes in patients with high blood pressure.

METHODS

The SEC trial employed four certified PFs across all practice sites, who documented time spent: (1) driving to support practices; (2) working on-site with staff and clinicians; and (3) communicating remotely (phone, email, or video conference) with practice members. We analyzed the data using descriptive statistics to help understand time devoted to individual and aggregated tasks. Additionally, we explored correlations between practice characteristics and time spent with PFs.

RESULTS

In aggregate, the PFs completed 416 visits to practices and spent an average of 130 (SD 65) min per visit driving to and from practices. The average time spent on-site per visit with practices was 87 (SD 37) min, while an average of 17 (SD 12) min was spent on individual remote communications. During the 12-month intervention, 1131 remote communications were conducted with practices. PFs spent most of their time with clinical staff members (n = 886 instances) or with practice managers alone (n = 670 instances) while relatively few on-site visits were conducted with primary care providers alone (n = 15). In 19 practices, no communications were solely with providers. No significant correlations were found between time spent on PF activities and a practices' percent of Medicaid and uninsured patients, staff-provider ratio, or federally qualified health center (FQHC) status.

CONCLUSIONS

PFs working with practices serving rural patients with hypertension devote substantial time to driving, highlighting the importance of optimizing a balance between time spent on-site vs. communicating remotely. Most time spent was with clinical staff, not primary care providers. These findings may be useful to researchers and business leaders who design, test, and implement efficient facilitation services.

TRIAL REGISTRATION

NIH ClinicalTrials.gov NCT02866669 . Registered on 15 August 2016. NHLBI AWARD number: PCS-1UH3HL130691.

HealthyRHearts - reducing cholesterol in rural adults via telehealth-based medical nutrition therapy: protocol for a cluster randomised controlled trial

BACKGROUND

Few randomised controlled trials specifically focus on prevention in rural populations. Cardiovascular disease (CVD) contributes to approximately one quarter of deaths in Australia. Nutrition is a key component affecting many risk factors associated with CVD, including hypercholesterolaemia. However, access to medical nutrition therapy (MNT) is limited for people living in rural areas, potentially exacerbating inequities related to health outcomes. Telehealth services present an opportunity to improve MNT access and address healthcare disparities for rural populations. The present study aims to evaluate feasibility, acceptability, and cost-effectiveness of a telehealth MNT CVD intervention program in lowering CVD risk over 12-months in regional and rural primary health care settings.

METHODS/DESIGN

A cluster randomised controlled trial set in rural and regional general practices in NSW, Australia, and their consenting patients (n = 300 participants). Practices will be randomised to either control (usual care from their General Practitioner (GP) + low level individualised dietetic feedback) or intervention groups (usual care from their GP + low level individualised dietetic feedback + telehealth MNT intervention). Telehealth consultations will be delivered by an Accredited Practising Dietitian (APD), with each intervention participant scheduled to receive five consultations over a 6-month period. System-generated generic personalised nutrition feedback reports are provided based on completion of the Australian Eating Survey - Heart version (AES-Heart), a food frequency questionnaire. Eligible participants must be assessed by their GP as at moderate (≥ 10%) to high (> 15%) risk of a CVD event within the next five years using the CVD Check calculator and reside in a regional or rural area within the Hunter New England Central Coast Primary Health Network (HNECC PHN) to be eligible for inclusion. Outcome measures are assessed at baseline, 3, 6 and 12 months. The primary outcome is reduction in total serum cholesterol. Evaluation of the intervention feasibility, acceptability and cost-effective will incorporate quantitative, economic and qualitative methodologies.

DISCUSSION

Research outcomes will provide knowledge on effectiveness of MNT provision in reducing serum cholesterol, and feasibility, acceptability, and cost-effectiveness of delivering MNT via telehealth to address CVD risk in rural regions. Results will inform translation to health policy and practice for improving access to clinical care in rural Australia.

TRIAL REGISTRATION

This trial is registered at anzctr.org.au under the acronym HealthyRHearts (Healthy Rural Hearts), registration number ACTRN12621001495819.

Responding to Health Outcomes and Access to Health and Hospital Services in Rural, Regional and Remote New South Wales

Ethical perspectives on regional, rural, and remote healthcare often, understandably and importantly, focus on inequities in access to services. In this commentary, we take the opportunity to examine the implications of normalizing metrocentric views, values, knowledge, and orientations, evidenced by the recent (2022) New South Wales inquiry into health outcomes and access to hospital and health services in regional, rural and remote New South Wales, for contemporary rural governance and justice debates. To do this, we draw on the feminist inspired approach to rural health ethics involving analysis of power relationships developed by Simpson and McDonald and related ideas from critical health sociology. In presenting this analysis, we extend contemporary thought about spatial health inequities and structural violence.

Understanding weight status and dietary intakes among Australian school children by remoteness: a cross-sectional study

OBJECTIVE

To determine whether primary school children's weight status and dietary behaviours vary by remoteness as defined by the Australian Modified Monash Model (MMM).

DESIGN

A cross-sectional study design was used to conduct secondary analysis of baseline data from primary school students participating in a community-based childhood obesity trial. Logistic mixed models estimated associations between remoteness, measured weight status and self-reported dietary intake.

SETTING

Twelve regional and rural Local Government Areas in North-East Victoria, Australia.

PARTICIPANTS

Data were collected from 2456 grade 4 (approximately 9-10 years) and grade 6 (approximately 11-12 years) students.

RESULTS

The final sample included students living in regional centres (17·4 %), large rural towns (25·6 %), medium rural towns (15·1 %) and small rural towns (41·9 %). Weight status did not vary by remoteness. Compared to children in regional centres, those in small rural towns were more likely to meet fruit consumption guidelines (OR: 1·75, 95 % CI (1·24, 2·47)) and had higher odds of consuming fewer takeaway meals (OR: 1·37, 95 % CI (1·08, 1·74)) and unhealthy snacks (OR = 1·58, 95 % CI (1·15, 2·16)).

CONCLUSIONS

Living further from regional centres was associated with some healthier self-reported dietary behaviours. This study improves understanding of how dietary behaviours may differ across remoteness levels and highlights that public health initiatives may need to take into account heterogeneity across communities.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia

BACKGROUND

The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia.

METHODS

From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data.

RESULTS

Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff.

CONCLUSIONS

Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

A theory-driven, culture-tailored educational intervention for cervical cancer screening among rural Chinese females: A feasibility and pilot study

Objective

This study aimed to evaluate the feasibility and preliminarily estimate the effects of a theory-driven, culture-tailored, community-based educational intervention promoting cervical cancer screening among rural females.

Methods

An experimental study with the two-arm parallel, nonrandomized control trial design was implemented, followed by individual semi-structured interviews. Thirty rural females between 26 and 64 were recruited, with 15 in each group. Both groups were exposed to the usual care about cervical cancer screening promotion from the local clinics, while participants in the intervention group additionally received five educational sessions in 5 weeks. Data were collected at baseline and immediately postintervention.

Results

All participants completed the study, and the retention rate was 100%. Participants in the intervention group had more significant increments in cervical cancer screening-related self-efficacy (P ​< ​0.001), knowledge (P ​< ​0.001), and intention levels (P ​= ​0.003) than those in the control group. Most participants showed acceptance and satisfaction with this educational intervention.

Conclusions

This study revealed that the theory-driven, culture-tailored, community-based educational intervention was feasible among the rural populations to promote cervical cancer screening. A large-scale interventional study with a prolonged follow-up duration is warranted to explore this educational intervention's effectiveness further.

The Power in Rural Place Stigma

The phenomenon and implications of stigma have been recognized across many contexts and in relation to many discrete issues or conditions. The notion of spatial stigma has been developed within stigma literature, although the importance and relevance of spatial stigma for rural places and rural people have been largely neglected. This is the case even within fields of inquiry like public and rural health, which are expansively tasked with addressing the socio-structural drivers of health inequalities. In this paper, we argue that developing a better understanding of rural place stigma is critical for addressing contemporary patterns of spatial injustice and health inequalities affecting rural communities globally. Drawing on international literature and examples from the reported experiences of rurally living Australians and news and other media, we present an analysis highlighting the power in rural place stigma. In doing so, we build a case for the relevance and importance of interrogating rural place stigma, especially in the fields of public and rural health, for changing the conditions within-and the broader positioning of-the rural in the public and political landscapes.

A Needs Assessment for Infectious Diseases Consultation in Community Hospitals

INTRODUCTION

Infectious diseases (ID) consultations have been demonstrated to improve patient outcomes in the treatment of severe infections. However, ID consultation is often unavailable to patients that live in rural communities. Little is known regarding the treatment of infections in rural hospitals with no coverage from an ID specialist. We characterized the outcomes of patients cared for in hospitals without coverage from an ID physician.

METHODS

Patients aged 18 years or older admitted to eight community hospitals without access to ID consultation during a 6.5-month period were assessed. All patients had received at least three days of continuous antimicrobial therapy. The primary outcome was the need for transfer to a tertiary facility for ID services. The secondary outcome was the characterization of antimicrobials received. Antimicrobial courses were evaluated independently by two board-certified ID physicians.

RESULTS

3706 encounters were evaluated. Transfers for ID consultation occurred in 0.01% of patients. The ID physician would have made modifications in 68.5% of patients. Areas for improvement included treatment of chronic obstructive pulmonary disease exacerbations, broad-spectrum treatment of skin and soft tissue infection, long courses of azithromycin, and management of Staphylococcus aureus bacteremia, including choice and length of therapy, as well as obtaining echocardiography. Patients evaluated received 22,807 days of antimicrobial therapy.

CONCLUSIONS

Patients hospitalized in community hospitals are rarely transferred for ID consultation. Our work demonstrates a need for ID consultation in community hospitals, identifying opportunities to enhance patient care by modifying antimicrobial regimens to improve antimicrobial stewardship and avoid inappropriate antimicrobials. Efforts to expand the ID workforce to include coverage at rural hospitals will likely improve antibiotic utilization.

Microbiological and chemical drinking water contaminants and associated health outcomes in rural Appalachia, USA: A systematic review and meta-analysis

In rural areas of the United States, an estimated ~1.8 million people lack reliable access to safe drinking water. Considering the relative dearth of information on water contamination and health outcomes in Appalachia, we conducted a systematic review of studies of microbiological and chemical drinking water contamination and associated health outcomes in rural Appalachia. We pre-registered our protocols, limiting eligibility to primary data studies published from 2000 to 2019, and searched four databases (PubMed, EMBASE, Web of Science, and the Cochrane Library). We used qualitative syntheses, meta-analyses, risk of bias analysis, and meta-regression to assess reported findings, with reference to US EPA drinking water standards. Of the 3452 records identified for screening, 85 met our eligibility criteria. 93 % of eligible studies (n = 79) used cross-sectional designs. Most studies were conducted in Northern (32 %, n = 27) and North Central (24 %, n = 20) Appalachia, and only 6 % (n = 5) in Central Appalachia. Across studies, E. coli were detected in 10.6 % of samples (sample-size-weighted mean percentage from 4671 samples, 14 publications). Among chemical contaminants, sample-size-weighted mean concentrations for arsenic were 0.010 mg/L (n = 21,262 samples, 6 publications), and 0.009 mg/L for lead (n = 23,259, 5 publications). 32 % (n = 27) of studies assessed health outcomes, but only 4.7 % (n = 4) used case-control or cohort designs (all others were cross-sectional). The most commonly reported outcomes were detection of PFAS in blood serum (n = 13), gastrointestinal illness (n = 5), and cardiovascular-related outcomes (n = 4). Of the 27 studies that assessed health outcomes, 62.9 % (n = 17) appeared to be associated with water contamination events that had received national media attention. Overall, based on the number and quality of eligible studies identified, we could not reach clear conclusions about the state of water quality, or its impacts on health, in any of Appalachia's subregions. More epidemiologic research is needed to understand contaminated water sources, exposures, and potentially associated health outcomes in Appalachia.

Something to eat: experiences of food insecurity on the farm

The health of farm owners and farmworkers has significant impacts on farm businesses, farming families, and local rural communities where agriculture is an important driver of social and economic activity. Rural residents and farmworkers have higher rates of food insecurity, but little is known about food insecurity among farm owners and the collective experiences of farm owners and farmworkers. Researchers and public health practitioners have stressed the need for policies that target the health and well-being of farm owners and farmworkers while remaining sensitive to the nature of life on the farm, yet farm owner and farmworker lived experiences have been understudied, especially in relation to one another. In-depth qualitative interviews were conducted with 13 farm owners and 18 farmworkers in Oregon. Modified grounded theory was used to analyze interview data. Data were coded using a three-stage process to identify salient core characteristics of food insecurity. Farm owner and farmworker meanings and interpretations of their food insecurity were often contradicted by evaluated food security scores using validated quantitative measures. According to such measures, 17 experienced high food security, 3 had marginal food security, and 11 had low food security, but narrative experiences suggested higher rates. Narrative experiences were categorized by core characteristics of food insecurity, including seasonal food shortages, resource stretching, working extended hours most days of the week, limited use of food assistance, and the tendency to downplay hardship. These unique factors have important implications for developing responsive policies and programs to support the health and well-being of farm livelihoods whose work enables health and well-being among consumers. Future studies to test the relationships between the core characteristics of food insecurity identified in this study and farm owner and farmworker meanings and interpretations of food insecurity, hunger, and nourishment are warranted.

Postpartum Depression in Young Mothers in Urban and Rural Indonesia

OBJECTIVES

Young mothers are vulnerable to postpartum depression due to role transition-related stress. Understanding the causes underlying these stressors is essential for developing effective interventions.

METHODS

This study analyzed the 2018 Indonesian Basic Health Research data. The Mini International Neuropsychiatric Interview was used to assess postpartum depression symptoms in mothers aged 15-24 years with infants aged 0-6 months. In 1285 subjects, the risk factors for postpartum depression were evaluated using multivariate logistic regression.

RESULTS

The overall prevalence of depression in the 6 months postpartum was 4.0%, with a higher prevalence in urban areas (5.7%) than in rural areas (2.9%). Urban and rural young mothers showed distinct postpartum depression risk factors. In urban areas, living without a husband (odds ratio [OR], 3.82; 95% confidence interval [CI], 1.24 to 11.76), experiencing preterm birth (OR, 4.67; 95% CI, 1.50 to 14.50), having pregnancy complications (OR, 3.03; 95% CI, 1.20 to 7.66), and having postpartum complications (OR, 5.23; 95% CI, 1.98 to 13.80) were associated with a higher risk of postpartum depression. In rural areas, postpartum depression was significantly associated with a smaller household size (OR, 3.22; 95% CI, 1.00 to 10.38), unwanted pregnancy (OR, 4.40; 95% CI, 1.15 to 16.86), and pregnancy complications (OR, 3.41; 95% CI, 1.31 to 8.88).

CONCLUSIONS

In both urban and rural contexts, postpartum depression relates to the availability of others to accompany young mothers throughout the postpartum period and offer support with reproductive issues. Support from the family and the healthcare system is essential to young mothers' mental health. The healthcare system needs to involve families to support young mothers' mental health from pregnancy until the postpartum period.

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

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