Are rural residents less likely to obtain recommended preventive healthcare services?

The Association of Established Primary Care with Postoperative Outcomes Among Medicare Patients with Digestive Tract Cancer

BACKGROUND

Primary care (PC) is essential to overall wellness and management of comorbidities. In turn, patients without adequate access to PC may face healthcare disparities. We sought to characterize the impact of established PC on postoperative outcomes among patients undergoing a surgical procedure for a digestive tract cancer.

METHODS

Medicare beneficiaries with a diagnosis of hepatobiliary, pancreas, and colorectal cancer between 2005 and 2019 were identified within the Surveillance, Epidemiology, and End Results program and Medicare-linked database. Individuals who did versus did not have PC encounters within 1-year before surgery were identified. A postoperative textbook outcome (TO) was defined as the absence of complications, no prolonged hospital stay, no readmission within 90 days, and no mortality.

RESULTS

Among 63,177 patients, 50,974 (80.7%) had at least one established PC visit before surgery. Patients with established PC were more likely to achieve TO (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09-1.19) with lower odds for complications (OR, 0.85; 95% CI, 0.72-0.89), extended hospital stay (OR, 0.86; 95% CI, 0.81-0.94), 90-day readmission (OR, 0.94; 95% CI, 0.90-0.99), and 90-day mortality (OR, 0.87; 95% CI, 0.79-0.96). In addition, patients with established PC had a 4.1% decrease in index costs and a 5.2% decrease in 1-year costs. Notably, patients who had one to five visits with their PC in the year before surgery had improved odds of TO (OR, 1.21; 95% CI, 1.16-1.27), whereas individuals with more than 10 visits had lower odds of a postoperative TO (OR, 0.91; 95% CI, 0.84-0.98).

CONCLUSION

Most Medicare beneficiaries with digestive tract cancer had established PC within the year before their surgery. Established PC was associated with a higher probability of achieving ideal outcomes and lower costs. In contrast, patients with more than 10 PC appointments, which was likely a surrogate of overall comorbidity burden, experienced no improvement in postoperative outcomes.

Identifying and Treating Those at Risk: Disparities in Rapid Relapse Among TNBC Patients in the National Cancer Database

PURPOSE

This study was designed to characterize features of rapid relapse TNBC (rrTNBC), an aggressive, poor prognosis breast cancer subset using the National Cancer Database (NCDB).

METHODS

Patients diagnosed with TNBC between 2010 and 2019 within NCDB were included in analyses. rrTNBC was defined as all-cause mortality ≤24 months from diagnosis. Patient demographic, tumor, and treatment association with rrTNBC were evaluated in univariate, bivariate analyses, and multiple logistic regression models. Two-part models are used to compare receipt of treatment (i.e., receipt of both chemotherapy and breast surgery) versus not in its relationship with rrTNBC.

RESULTS

Overall, 14.5% of patients were categorized as rrTNBC. Age older than 75 years (-41.3%), Black race (-1.4%), Medicare (-2.6%), and Charlson-Deyo score ≥2 (-4.9%) were associated with a lower probability of receiving both chemotherapy and breast surgery. Not receiving both treatments (vs. receiving both chemotherapy and breast surgery) was associated with a two-to-three-fold higher probability of rrTNBC among patients aged older than 75 years (16.6% vs. 6%), having Medicare (3.6% vs. 1.6%), and Charlson-Deyo score ≥2 (16.6% vs. 5.9%).

CONCLUSIONS

Age, insurance, and comorbidity were related to a lower likelihood of treatment; yet receiving treatment reduced the risk of rrTNBC threefold for each. These findings might be valuable to inform clinical care delivery, as well as future research that examines treatment protocols among diverse patients.

Multiple risk-taking behaviors in Korean adolescents and associated factors: 2020 and 2021 Korea youth risk behavior web-based survey

OBJECTIVE

Despite the negative health impact of multiple risk-taking behaviors (RTBs), there is a lack of understanding of adolescents who are more prone to multiple RTBs. This study aimed to identify sociodemographic, mental, and physical health variables associated with increased susceptibility to multiple RTBs in each sex.

METHODS

Cross-sectional data from the 2020 and 2021 Korea Youth Risk Behavior Web-based Survey was used. A total of 106,979 Korean adolescents (55,460 men and 51,519 women) were assessed on five RTBs (alcohol use, smoking, sexual intercourse, illicit substance use, no seat belt wearing). In comparison to no RTB group, odds ratios of the relevant covariate factors were calculated in one RTB or multiple RTBs groups.

RESULTS

Male and female adolescents engaging in multiple RTBs were 6.4% and 3.8%, respectively. Increasing age, low subjective socioeconomic status, and living in rural areas were associated with multiple RTBs regardless of sex. All mental health variables except anxiety were associated with multiple RTBs in both sexes. Physical inactivity and obesity were associated with decreased odds of multiple RTBs in both sexes.

CONCLUSION

This study identifies diverse factors associated with multiple RTBs of Korean adolescents and demonstrates existing sex differences. Age and mental health status are the most critical factors that distinguish multiple risk-taking groups from those involved in one or no RTB.

Strategies used to reduce harms associated with fentanyl exposure among rural people who use drugs: multi-site qualitative findings from the rural opioid initiative

AIM

Illicitly manufactured fentanyl and its analogs are the primary drivers of opioid overdose deaths in the United States (U.S.). People who use drugs may be exposed to fentanyl or its analogs intentionally or unintentionally. This study sought to identify strategies used by rural people who use drugs to reduce harms associated with unintentional fentanyl exposure.

METHODS

This analysis focused on 349 semi-structured qualitative interviews across 10 states and 58 rural counties in the U.S conducted between 2018 and 2020. Interview guides were collaboratively standardized across sites and included questions about drug use history (including drugs currently used, frequency of use, mode of administration) and questions specific to fentanyl. Deductive coding was used to code all data, then inductive coding of overdose and fentanyl codes was conducted by an interdisciplinary writing team.

RESULTS

Participants described being concerned that fentanyl had saturated the drug market, in both stimulant and opioid supplies. Participants utilized strategies including: (1) avoiding drugs that were perceived to contain fentanyl, (2) buying drugs from trusted sources, (3) using fentanyl test strips, 4) using small doses and non-injection routes, (5) using with other people, (6) tasting, smelling, and looking at drugs before use, and (7) carrying and using naloxone. Most people who used drugs used a combination of these strategies as there was an overwhelming fear of fatal overdose.

CONCLUSION

People who use drugs living in rural areas of the U.S. are aware that fentanyl is in their drug supply and use several strategies to prevent associated harms, including fatal overdose. Increasing access to harm reduction tools (e.g., fentanyl test strips, naloxone) and services (e.g., community drug checking, syringe services programs, overdose prevention centers) should be prioritized to address the polysubstance-involved overdose crisis. These efforts should target persons who use opioids and other drugs that may contain fentanyl.

The Urban-Rural Divide in Neurocritical Care in Low-Income and Middle-Income Countries

The term "urban-rural divide" encompasses several dimensions and has remained an important concern for any country. The economic disparity; lack of infrastructure; dearth of medical specialists; limited opportunities to education, training, and health care; lower level of sanitation; and isolating effect of geographical location deepens this gap, especially in low-income and middle-income countries (LMICs). This article gives an overview of the rural-urban differences in terms of facilities related to neurocritical care (NCC) in LMICs. Issues related to common clinical conditions such as stroke, traumatic brain injury, myasthenia gravis, epilepsy, tubercular meningitis, and tracheostomy are also discussed. To facilitate delivery of NCC in resource-limited settings, proposed strategies include strengthening preventive measures, focusing on basics, having a multidisciplinary approach, promoting training and education, and conducting cost-effective research and collaborative efforts. The rural areas of LMICs bear the maximum impact because of their limited access to preventive health services, high incidence of acquired brain injury, inability to have timely management of neurological emergencies, and scarcity of specialist services in a resource-deprived health center. An increase in the health budget allocation for rural areas, NCC education and training of the workforce, and provision of telemedicine services for rapid diagnosis, management, and neurorehabilitation are some of the steps that can be quite helpful.

The impact of decentralization of health services at the municipal level on health outcomes: evidence from China

Objectives

Under the system of health decentralization, there are differences in the level of expenditure decentralization at different levels of government, and their impact on residents' health may also be different. This paper is one of the first to evaluate the effect of decentralization of health services at the municipal level from a multi-dimensional health perspective.

Data and methods

This paper uses the data of expenditure decentralization of health services at the municipal level to match the panel data from the China Household Panel Survey (CFPS) from 2010 to 2018, and uses the logit model, ordered logit model and two-way fixed effects model to empirically analyze the impact of health decentralization at the municipal level on health outcomes.

Results

Based on the perspective of multi-dimensional health, from the three aspects of physical health, depression status and cognitive ability, the six sub-indicators of self-rated health, BMI standards, depression scores (summation method), depression scores (factor method), phrase test scores and mathematics test scores are discussed separately. The results show that the decentralization of health services at the municipal level has a significant promotion effect on the multi-dimensional health of residents.

Conclusion

The decentralization of health services at the municipal level has important theoretical significance for promoting the reasonable division of medical and health powers and expenditure responsibilities between provincial and municipal governments, improving the efficiency of health expenditure funds, and establishing a fiscal system that matches financial resources.

Telehealth Trends and Hypertension Management Among Rural and Medicaid Patients After COVID-19

Objective: Examine the associations between rurality and low income with primary care telehealth utilization and hypertension outcomes across multiple years pre- and post-COVID-19 pandemic onset. Methods: We compiled electronic health record data from the mixed rural/urban Dartmouth Health system in New Hampshire, United States, on patients with pre-existing hypertension or diabetes receiving primary care in the period before (January 2018-February 2020) and after the transition period to telehealth during the COVID-19 Pandemic (October 2020-December 2022). Stratifying by rurality and Medicaid enrollment, we examined changes in synchronous (office and telehealth visits, including audio/video use) and asynchronous (patient portal or telephone message) utilization, and control of mean systolic blood pressure (SBP) <140. Results: Analysis included 46,520 patients, of whom 8.2% were Medicaid enrollees, 42.7% urban residents. Telehealth use rates were 12% for rural versus 6.4% for urban, and 15% for Medicaid versus 8.4% non-Medicaid. The overall postpandemic telehealth visit rate was 0.29 per patient per year. Rural patients had a larger increase in telehealth use (additional 0.21 per year, 95% CI, 0.19-0.23) compared with urban, as did Medicaid (0.32, 95% CI 0.29-0.36) compared with non-Medicaid. Among the 38,437 patients with hypertension, SBP control worsened from 83% to 79% of patients across periods. In multivariable analysis, rurality corresponded to worsened control rates compared with urban (additional 2.4% decrease, 95% CI 2.1-2.8%); Medicaid and telehealth use were not associated with worsened control. Conclusions: Telehealth expansion enabled a higher shift to telehealth for rural and low-income patients without impairing hypertension management.

The Impact of a Student-Led Health Education Clinic on the Health Literacy and Behaviors of a Rural Community in the State of Pennsylvania, USA

Rural populations experience a number of disparities that place them at increased risk of morbidity and mortality related to chronic disease, including lower health literacy and greater distance to medical care. Community-based free healthcare education can offer targeted preventive care to these vulnerable populations; however, limited quantitative research exists measuring their impact, specifically on health literacy and likelihood for behavior change. To investigate this, a student-led health education clinic was held in January 2023 in the rural community of Lykens, Pennsylvania by the Student-run and Collaborative Outreach Program for Health Equity (SCOPE). Fifty-five pre- and post-clinic surveys using Likert-style questions measured the knowledge and likelihood of behavioral change for several preventive health topics, including hypertension, diabetes mellitus, cancer screenings, childhood vaccinations, skin cancer, mental health, addiction, and nutrition. From pre- to post-clinic, there was a significant increase in knowledge of hypertension (p = 0.023) and diabetes (p = 0.014), likelihood of attending cancer screenings (p = 0.038), and confidence in identifying cancerous moles (p = < 0.001). There was a non-significant increase in understanding of mental health and nutrition, and no change in understanding of addiction or childhood vaccinations. It is likely that the level of interaction in education provided and relevance of information to participants contributed to effective uptake of information. The results demonstrate an immediate impact on health literacy and likelihood of behavioral change for several important preventive health topics, and advocate for the use of student-run healthcare interventions in addressing the prevalence of chronic disease in rural communities.

Differences in cancer presentation, treatment, and mortality between rural and urban patients diagnosed with kidney cancer in the United States

INTRODUCTION

Rural-urban discrepancies in care and outcomes for kidney cancer (KCa) in the United States remains poorly understood. Our study aims to improve our understanding of the influence of rurality on KCa outcomes in the United States by analyzing differences in presentation, treatment, and mortality between urban areas (UAs) and rural areas (RAs) in the Surveillance, Epidemiology, and End Results (SEERs) database.

METHODS

SEERs data was queried from 2000 to 2019 for KCa patients. Patient counties were classified as UAs, rural adjacent areas (RAAs), or rural nonadjacent areas (RNAs) using Rural Urban Continuum Codes. Demographic, tumor characteristics, and treatment variables were compared. Propensity score matching was performed to create matched UA-RAA and UA-RNA cohorts. Multivariate regression evaluated rural-urban status as a predictor of treatment selection. Multivariate cox regression assessed the predictive value of rural-urban status for overall survival (OS) and cancer-specific survival (CSS). Kaplan-Meier analysis was used to generate survival curves for OS and CSS.

RESULTS

179,509 KCa patients were identified (UA = 87.0%, RAA = 7.7%, RNA = 5.3%). Patients in RAs were more likely to present with tumors of higher grade and stage than UAs. Following multivariate analysis, rural residency predicted undergoing nephrectomy (RAA: OR = 1.177, RNA: OR = 1.210) but was a negative predictor of receiving partial nephrectomy (RAA: OR = 0.744, RNA: OR = 0.717), all P < 0.001. Multivariate cox regression demonstrated that RAA or RNA residency was predictive of overall and cause-specific mortality. After matching, median OS was 151, 124, and 118 months for UA, RAA, and RNA cohorts respectively; mean CSS was 152, 147, and 144 months for UA, RAA, and RNA cohorts, respectively, all P < 0.001. Stage-specific analysis of CSS demonstrated significantly poorer CSS among RNA patients for localized, regionalized, and distant KCa after matching. Only RAA patients with localized KCa experienced significantly lower CSS than UA patients.

CONCLUSIONS

Patients in RAs are more likely to present with advanced KCa at diagnosis compared to those in UAs and may also experience different treatment options including a lesser likelihood of undergoing partial nephrectomy. Rural patients with KCa also demonstrated significantly worse OS and CSS compared to their urban counterparts. Further patient-level studies are required to better understand the discrepancy in CSS between urban and rural patients diagnosed with KCa.

Examining the roles of travel distance, medical mistrust, and cancer fatalism in the uptake of clinical cancer prevention among women in rural and urban US communities: A secondary data analysis

Introduction

Rural adults are less likely to receive cancer screening than urban adults, likely due to systematic differences in community- and individual-level factors. The purpose of this study was to analyze the relative contributions of rurality, travel time, medical mistrust, and cancer fatalism in explaining uptake of clinical cancer prevention services.

Methods

We conducted a secondary data analysis of 2019-2020 survey data from women, ages 45-65, in rural and urban counties in central Pennsylvania, examining rurality, travel time to a primary care provider, medical mistrust, and cancer fatalism, as well as uptake of guideline-recommended colorectal cancer screening, cervical cancer screening, and preventive check-up. Final models used multivariable logistic regression to assess the relationships among study variables, controlling for participant demographics.

Results

Among 474 participants, 48.9 % resided in rural counties. Most participants had received clinical cancer prevention services (colorectal cancer screening: 55.4 %; cervical cancer screening: 82.8 %; preventive check-up in the last year: 75.4 %). Uptake of services was less common among participants with higher medical mistrust (colorectal cancer screening: adjusted odds ratio [aOR] = 0.87, 95 % confidence interval [CI] = 0.76-1.00; cervical cancer screening: aOR = 0.79, 95 % CI = 0.63-1.00; last-year check-up: aOR = 0.74, 95 % CI = 0.63-0.88).

Conclusions

Patient attitudes, particularly medical mistrust, may contribute to rural/urban disparities in clinical cancer prevention among women. Community- and individual-level interventions are needed to improve cancer outcomes in rural areas.

Evaluating the Connection Between Rural Travel Time and Health: A Cross-Sectional Analysis of Older Adults Living in the Northeast United States

INTRODUCTION

To characterize the impact of rural patients' travel time to obtain healthcare on their reported utilization of preventive healthcare services and personal health outcomes.

METHODS

Online survey data from rural adults ages 50+ years living in the Northeastern United States were collected from February to August 2021. Study measures included self-reported travel time to obtain healthcare, use of preventive healthcare, and health outcomes. The associations between travel time with use of preventive care and health outcomes were assessed using linear, Poisson, and logistic regression analyses controlling for demographic variables.

RESULTS

Our study population included 1052 rural adults, with a mean travel time of 18.5 min (range: 0-60). Travel time was greater for racial/ethnic minority participants and for higher-income participants (both P < .05), but it was not associated with use of preventive healthcare. Greater travel time was associated with poorer mental health and more comorbidities, including cancer and diabetes (all P < .05).

CONCLUSIONS

Travel time varied by patient demographic factors, and it was associated with mental health and comorbidities. There was no association between travel time and preventive care use, suggesting that other barriers likely contribute to suboptimal use of these services within rural communities. Further research is needed to elucidate the causal pathways linking travel time to mental health and comorbidities within rural communities, as increased travel may exacerbate intrarural health disparities.

Rural/Urban differences in uptake of preventive healthcare services: Variability in observed relationships across measures of rurality

Rural residents are generally less likely to receive preventive healthcare than are urban residents, but variable measurement of rurality introduces inconsistency to these findings. We assessed the relationships between perceived and objective measures of rurality and uptake of preventive healthcare. In our sample, rural participants generally had equal or higher uptake of healthcare (i.e. private health insurance, check-up in the past year, being up-to-date on colorectal and cervical cancer screening) than urban participants. Importantly, the perceived measure of rurality performed similarly to the objective measures, suggesting that participant report could be a valid way to assess rurality in health studies. Significance for Public Health The ability to access routine preventive healthcare is a key component of public health. Comparing uptake of cancer screening in rural versus urban areas is one way to assess equity of healthcare access. Generally, rural areas have a higher burden of cancer than urban areas. The built environment, socioeconomic status, and patient perceptions can impact an individual's access to routine cancer screening. Preventive healthcare is of great importance to public health as a whole because screening can facilitate earlier diagnosis and more successful treatment for many preventable cancers, which may ultimately increase the quality and quantity of life.

Fragmentation of Care in Patients with Peritoneal Metastases Undergoing Cytoreductive Surgery

BACKGROUND

The delivery of multimodal treatment at a high-volume center is known to optimize the outcomes of gastrointestinal malignancies. However, patients undergoing cytoreductive surgery (CRS) for peritoneal metastases often must 'fragment' their surgical and systemic therapeutic care between different institutions. We hypothesized that this adversely affects outcomes.

PATIENTS AND METHODS

Adults undergoing CRS for colorectal or appendiceal adenocarcinoma at our institution between 2016 and 2022 were identified retrospectively and grouped by care network: 'coordinated care' patients received exclusively in-network systemic therapy, while 'fragmented care' patients received some systemic therapy from outside-network providers. Factors associated with fragmented care were also ascertained. Overall survival (OS) from CRS and systemic therapy-related serious adverse events (SAEs) were compared across the groups.

RESULTS

Among 85 (80%) patients, 47 (55%) had colorectal primaries and 51 (60%) received fragmented care. Greater travel distance [OR 1.01 (CI 1.00-1.02), p = 0.02] and educational status [OR 1.04 (CI 1.01-1.07), p = 0.01] were associated with receiving fragmented care. OS was comparable between patients who received fragmented and coordinated care in the colorectal [32.5 months versus 40.8 months, HR 0.95 (CI 0.43-2.10), p = 0.89] and appendiceal [31.0 months versus 27.4 months, HR 1.17 (CI 0.37-3.74), p = 0.55] subgroups. The frequency of SAEs (7.8% versus 17.6%, p = 0.19) was also similar.

CONCLUSIONS

There were no significant differences in survival or SAEs based on the networks of systemic therapy delivery. This suggests that patients undergoing CRS at a high-volume center may safely receive systemic therapy at outside-network facilities with comparable outcomes.

A Christian Faith-Based Facebook Intervention for Smoking Cessation in Rural Communities (FAITH-CORE): Protocol for a Community Participatory Development Study

BACKGROUND

Tobacco smoking remains the leading cause of preventable morbidity and mortality in the United States, with significant rural-urban disparities. Adults who live in rural areas of the United States have among the highest tobacco smoking rates in the nation and experience a higher prevalence of smoking-related deaths and deaths due to chronic diseases for which smoking is a causal risk factor. Barriers to accessing tobacco use cessation treatments are a major contributing factor to these disparities. Adults living in rural areas experience difficulty accessing tobacco cessation services due to geographical challenges, lack of insurance coverage, and lack of health care providers who treat tobacco use disorders. The use of digital technology could be a practical answer to these barriers.

OBJECTIVE

This report describes a protocol for a study whose main objectives are to develop and beta test an innovative intervention that uses a private, moderated Facebook group platform to deliver peer support and faith-based cessation messaging to enhance the reach and uptake of existing evidence-based smoking cessation treatment (EBCT) resources (eg, state quitline coaching programs) for rural adults who smoke.

METHODS

We will use the Integrated Theory of Health Behavior Change, surface or deep structure frameworks to guide intervention development, and the community-based participatory research (CBPR) approach to identify and engage with community stakeholders. The initial content library of moderator postings (videos and text or image postings) will be developed using existing EBCT material from the Centers for Disease Control and Prevention Tips from Former Smokers Campaign. The content library will feature topics related to quitting smoking, such as coping with cravings and withdrawal and using EBCTs with faith-based message integration (eg, Bible quotes). A community advisory board and a community engagement studio will provide feedback to refine the content library. We will also conduct a beta test of the intervention with 15 rural adults who smoke to assess the recruitment feasibility and preliminary intervention uptake such as engagement, ease of use, usefulness, and satisfaction to further refine the intervention based on participant feedback.

RESULTS

The result of this study will create an intervention prototype that will be used for a future randomized controlled trial.

CONCLUSIONS

Our CBPR project will create a prototype of a Facebook-delivered faith-based messaging and peer support intervention that may assist rural adults who smoke to use EBCT. This study is crucial in establishing a self-sufficient smoking cessation program for the rural community. The project is unique in using a moderated social media platform providing peer support and culturally relevant faith-based content to encourage adult people who smoke to seek treatment and quit smoking.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52398.

Urban-rural differences in hypertension prevalence, blood pressure control, and systolic blood pressure levels

Higher rates of cardiovascular events have been observed among rural residents compared with urban. Hypertension and lack of blood pressure (BP) control are risk factors for cardiovascular events. We compared the prevalence of hypertension and controlled BP, and the distribution of systolic blood pressure (SBP), by urban-rural residence. Participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, a prospective cohort of Black and White adults aged ≥45 years, were categorized as either urban, large rural, or small-isolated rural, by using the Rural-Urban Commuting Area (RUCA) categorization B system. Oucomes were hypertension prevalence (BP ≥ 140/90 mmHg or antihypertensive use), BP control (BP < 140/90 among participants on antihypertensive medication), and the distribution of SBP. Counfounders were age, race, sex, antihypertensive medication use, and US Census Bureau division. The analysis included 26,133 participants (80.3% urban, 11.6% large-rural, 8.2% small-isolated rural). The unadjusted prevalence of hypertension was not different between groups. However, after adjustment, the odds of hypertension was higher among participants in the large rural group (odds ratio [OR] 1.17; 95% confidence interval [CI], 1.08-1.27) and small-isolated rural group (OR 1.19; 95% CI, 1.08-1.30), compared with the urban group. There was no evidence of an adjusted difference in BP control for those taking antihypertensive medications. Adjusted differences in SBP were greater for both rural groups, compared with urban, at the higher percentiles of SBP. Rural residence was associated with a higher adjusted odds of hypertension and higher SBP.

Potential bias and lack of generalizability in electronic health record data: reflections on health equity from the National Institutes of Health Pragmatic Trials Collaboratory

Embedded pragmatic clinical trials (ePCTs) play a vital role in addressing current population health problems, and their use of electronic health record (EHR) systems promises efficiencies that will increase the speed and volume of relevant and generalizable research. However, as the number of ePCTs using EHR-derived data grows, so does the risk that research will become more vulnerable to biases due to differences in data capture and access to care for different subsets of the population, thereby propagating inequities in health and the healthcare system. We identify 3 challenges-incomplete and variable capture of data on social determinants of health, lack of representation of vulnerable populations that do not access or receive treatment, and data loss due to variable use of technology-that exacerbate bias when working with EHR data and offer recommendations and examples of ways to actively mitigate bias.

Parental intention to vaccinate children against seasonal influenza in the Eastern Mediterranean region: A cross-sectional study using the health belief model

Seasonal influenza vaccine is the most effective strategy for reducing influenza incidence and severity. Parental decision-making regarding childhood vaccination is influenced by one's vaccine-related beliefs. A cross-sectional study was conducted to determine the role of the Health Belief Model (HBM) in predicting parental intention to vaccinate their children against influenza in the Eastern Mediterranean Region (EMR). An anonymous online survey was distributed to parents of children aged 6 months to 18 years in 14 EMR countries. Out of the 5964 participants, 28.2% intended to vaccinate their children against influenza. Urban residents (OR = 0.55, 95%CI: 0.35-0.85), decision-making regarding child's health by the father alone (OR = 0.43, 95%CI: 0.34-0.55) or the mother alone (OR = 0.78, 95%CI: 0.65-0.93), having a child with a chronic illness (OR = 0.45, 95%CI: 0.38-0.53), reporting high perceived severity, susceptibility, and benefits (OR = 0.35, 95%CI: 0.30-0.40), and cues to action (OR = 0.45, 95%CI: 0.39-0.51) were inversely associated with parental unwillingness to vaccinate their children against influenza. While parents with a higher number of children in the household (OR = 1.08, 95%CI:1.03-1.12) and higher perceived barriers (OR = 2.92, 95%CI: 2.56-3.34) showed an increased likelihood of unwillingness to vaccinate their children. Interventions targeting parental beliefs and perceptions are necessary to improve influenza vaccination acceptance and coverage among children.

Using wastewater to overcome health disparities among rural residents

The SARS-CoV-2 pandemic highlighted the need for novel tools to promote health equity. There has been a historical legacy around the location and allocation of public facilities (such as health care) focused on efficiency, which is not attainable in rural, low-density, United States areas. Differences in the spread of the disease and outcomes of infections have been observed between urban and rural populations throughout the COVID-19 pandemic. The purpose of this article was to review rural health disparities related to the SARS-CoV-2 pandemic while using evidence to support wastewater surveillance as a potentially innovative tool to address these disparities more widely. The successful implementation of wastewater surveillance in resource-limited settings in South Africa demonstrates the ability to monitor disease in underserved areas. A better surveillance model of disease detection among rural residents will overcome issues around the interactions of a disease and social determinants of health. Wastewater surveillance can be used to promote health equity, particularly in rural and resource-limited areas, and has the potential to identify future global outbreaks of endemic and pandemic viruses.

Determinants of province-based health service utilization according to Andersen' s Behavioral Model: a population-based spatial panel modeling study

OBJECTIVE

The Andersen' s Behavioral Model was used to explore the impact of various factors on the utilization of health services. The purpose of this study is to establish a provincial-level proxy framework for the utilization of health services from a spatial perspective, based on the influencing factors of the Andersen' s Behavioral Model.

METHOD

Provincial-level health service utilization was estimated by the annual hospitalization rate of residents and the average number of outpatient visits per year from China Statistical Yearbook 2010-2021. Exploring the relevant influencing factors of health service utilization using the spatial panel Durbin model. Spatial spillover effects were introduced to interpret the direct and indirect effects influenced by the proxy framework for predisposing, enabling, and need factors on health services utilization.

RESULTS

From 2010 - 2020, the resident hospitalization rate increased from 6.39% ± 1.23% to 15.57% ± 2.61%, and the average number of outpatient visits per year increased from 1.53 ± 0.86 to 5.30 ± 1.54 in China. For different provinces, the utilization of health services is uneven. The results of the Durbin model show that locally influencing factors were statistically significantly related to an increase in the resident hospitalization rate, including the proportion of 65-year-olds, GDP per capita, percentage of medical insurance participants, and health resources index, while statistically related to the average number of outpatient visits per year, including the illiteracy rate and GDP per capita. Direct and indirect effects decomposition of resident hospitalization rate associated influencing factors demonstrated that proportion of 65-year-olds, GDP per capita, percentage of medical insurance participants, and health resources index not only affected local resident hospitalization rate but also exerted spatial spillover effects toward geographical neighbors. The illiteracy rate and GDP per capita have significant local and neighbor impacts on the average number of outpatient visits.

CONCLUSION

Health services utilization was a variable varied by region and should be considered in a geographic context with spatial attributes. From the spatial perspective, this study identified the local and neighbor impacts of predisposing factors, enabling factors, and need factors that contributed to disparities in local health services utilization.

Urban and Rural Mpox Incidence Among Persons Aged 15-64 Years - United States, May 10-December 31, 2022

During May 10-December 31, 2022, a total of 29,980 confirmed and probable^† U.S. monkeypox (mpox) cases were reported to CDC, predominantly in cisgender adult men reporting recent same-gender sexual partners (1). Urban-rural differences in health (2) and diagnosis of HIV (3,4) and other sexually transmitted infections (5) are well documented nationally. This report describes urban-rural differences in mpox incidence (cases per 100,000 population) among persons aged 15-64 years, by gender and race and ethnicity. Urbanicity was assessed using the 2013 National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties (2). Substantial differences in incidence by urbanicity, gender, and race and ethnicity were observed; most (71.0%) cases occurred in persons residing in large central urban areas. Among the cases in large central urban areas, most (95.7%) were in cisgender men. The overall incidence of mpox in the United States was 13.5 per 100,000 persons aged 15-64 years and peaked in August in both urban and rural areas. Among cisgender men, incidence in rural areas was approximately 4% that in large central urban areas (risk ratio [RR] = 0.04). Among cisgender women, incidence in rural areas was approximately 11% that in large central urban areas (RR = 0.11). In both urban and rural areas, incidence among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) persons was consistently higher than that among non-Hispanic White (White) persons; RRs between Black and White persons were highest in rural areas. Support and maintenance of mpox surveillance and prevention efforts including vaccinations should focus on urban areas with the highest incidence of mpox during the 2022 outbreak; however, surveillance and prevention efforts should include all genders, persons of color, and persons residing in both urban and rural areas who are at increased risk for mpox.

Racial differences in COVID-19 vaccine acceptance in Arkansas

Vaccines are one of the most successful tools for protecting the public's health. However, widespread vaccine hesitancy in the Southern United States is preventing effective mitigation of the current COVID-19 pandemic. The purpose of this study was to assess COVID-19 vaccine acceptance among adults living in a largely rural Southern state. This cross-sectional study collected data from 1,164 Arkansas residents between October 3 and October 17, 2020 using random digit dialing. The primary outcome was a multidimensional COVID-19 vaccine acceptance measure with scores between -3 to +3. The full COVID-19 vaccine acceptance scale was measured along with perceived vaccine safety, effectiveness, acceptance, value, and legitimacy subscales. Statistical analyses were conducted using multivariable linear regression. Results indicated Black participants had the lowest overall vaccine acceptance (0.5) compared to White participants (1.2). Hispanic participants had the highest scores (1.4). In adjusted models, Black participants had 0.81 points lower acceptance than White participants, and Hispanic participants had 0.35 points higher acceptance. Hispanic participants had the highest scores for all five vaccine acceptance subscales, relatively equivalent to White participants. Black participants had consistently lower scores, especially perceived vaccine safety (mean -0.2, SD 0.1). In conclusion, the lowest vaccine acceptance rates were among Black participants particularly on perceived vaccine safety. While Black participants had the lowest acceptance scores, Hispanic participants had the highest. This variability shows the value of a multidimensional vaccine acceptance measure to inform COVID-19 vaccination campaign strategies.

Determinants of parental seasonal influenza vaccine hesitancy in the Eastern Mediterranean region: A cross-sectional study

Background

Seasonal influenza vaccine can reduce the risk of influenza-associated hospitalizations and deaths among children. Given that parents are the primary decision makers, this study examined the parental attitude toward childhood influenza vaccine and identified determinants of vaccine hesitancy (VH) in the Eastern Mediterranean region (EMR).

Methods

A cross-sectional study was conducted using an anonymous online survey in 14 EMR countries. Parents of children aged 6 months to 18 years were included. The Parent Attitude about Childhood Vaccines (PACV) was used to assess VH. Chi square test and independent t-test were used to test for association of qualitative and quantitative variables, respectively. A structural equations model (SEM) was used to identify direct and indirect determinants of parental VH.

Results

Almost half of the parents were hesitant about vaccinating their children against influenza (50.8%). Parental VH was significantly higher among older mothers (37.06 ± 8.8 years, p = 0.006), rural residents (53.6%, p &lt; 0.001), high-income countries residents (50.6%, p &lt; 0.001), and mothers with higher educational levels (52.1%, p &lt; 0.001). Parents of school-aged children (5–9 years) (55.6%, p &lt; 0.001), children free from any comorbidities (52.5%, p &lt; 0.001), children who did not receive routine vaccination at all (51.5%, p = 0.03), children who were not vaccinated against COVID-19 (54.3%, p &lt; 0.001), in addition to parents who were not vaccinated against influenza (57.1%, p &lt; 0.001) were significantly associated with increased likelihood of VH. Parents who were depending on healthcare provider as a source of information regarding vaccines were less likely to report VH (47.9%, p &lt; 0.001), meanwhile those who used social media as their source of health information showed a significantly higher VH (57.2%, p &lt; 0.001). The SEM suggested that mother’s age, residence, country income level, child gender, total number of children and source of information regarding vaccines had a direct effect on VH. Meanwhile, parents vaccinated against influenza, children completely or partially vaccinated with routine vaccines and children vaccinated against Coronavirus disease 2019 (COVID-19) had an indirect effect on VH.

Conclusion

A high proportion of included parents were hesitant to vaccinate their children against seasonal influenza. This attitude is due to many modifiable and non-modifiable factors that can be targeted to improve vaccination coverage.

Association of 3-year change in sleep duration with risk of all-cause mortality in Chinese older population: A national cohort study

BACKGROUND

Existing evidence on the association of dynamic change in sleep duration with risk of all-cause mortality in Chinese older population is limited. We aimed to explore the association of 3-year change in sleep duration with risk of all-cause mortality in a Chinese older population.

MATERIALS AND METHODS

A total of 5772 Chinese older participants (median age 82 years) were enrolled in the current study. Cox proportional-hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of 3-year change in sleep duration with risk of all-cause mortality. Subgroup analyses of the association between 3-year change in sleep duration and risk of all-cause mortality were conducted by age, sex and residence.

RESULTS

During a median of 4.08 years of follow-up, death developed in 1762 participants. Compared with -1 to <1 h/day change in sleep duration, the adjusted risk of all-cause mortality with < -3 h/day change in sleep duration may increase 26% (HR = 1.26, 95% CI: 1.05-1.52); the risk of all-cause mortality with 3-year change from short to long sleep duration, or long to short sleep duration versus stable normal sleep duration status was increased about 28% and 52%, respectively (HR = 1.28, 95% CI: 1.00-1.64 and HR = 1.52, 95% CI: 1.21-1.92). Subgroup analyses demonstrated that similar significant associations were observed among participants with 65 to <85 years, men and living in city and town.

CONCLUSIONS

Dynamic sleep duration change was significantly associated with risk of all-cause mortality. The current study suggests that sleep duration may be a non-invasive indicator for interventions aiming to reduction risk of all-cause mortality in Chinese older population.

How the rural risk environment underpins hepatitis C risk: Qualitative findings from rural southern Illinois, United States

BACKGROUND

Hepatitis C virus (HCV) infection has increased among persons who inject drugs (PWID) in the United States with disproportionate burden in rural areas. We use the Risk Environment framework to explore potential economic, physical, social, and political determinants of hepatitis C in rural southern Illinois.

METHODS

Nineteen in-depth semi-structured interviews were conducted with PWID from August 2019 through February 2020 (i.e., pre-COVID-19 pandemic) and four with key informants who professionally worked with PWID. Interviews were recorded, professionally transcribed, and coded using qualitative software. We followed a grounded theory approach for coding and analyses.

RESULTS

We identify economic, physical, policy, and social factors that may influence HCV transmission risk and serve as barriers to HCV care. Economic instability and lack of economic opportunities, a lack of physically available HCV prevention and treatment services, structural stigma such as policies that criminalize drug use, and social stigma emerged in interviews as potential risks for transmission and barriers to care.

CONCLUSION

The rural risk environment framework acknowledges the importance of community and structural factors that influence HCV infection and other disease transmission and care. We find that larger structural factors produce vulnerabilities and reduce access to resources, which negatively impact hepatitis C disease outcomes.

Does fragmented cancer care affect survival? Analysis of gastric cancer patients using national insurance claim data

BACKGROUND

We aimed to investigate the association between fragmented cancer care in the early phase after cancer diagnosis and patient outcomes using national insurance claim data.

METHODS

From a nationwide sampled cohort database, we identified National Health Insurance beneficiaries diagnosed with gastric cancer (ICD-10: C16) in South Korea during 2005-2013. We analyzed the results of a multiple logistic regression analysis using the generalized estimated equation model to investigate which patient and institution characteristics affected fragmented cancer care during the first year after diagnosis. Then, survival analysis using the Cox proportional hazard model was conducted to investigate the association between fragmented cancer care and five-year mortality.

RESULTS

Of 2879 gastric cancer patients, 11.9% received fragmented cancer care by changing their most visited medical institution during the first year after diagnosis. We found that patients with fragmented cancer care had a higher risk of five-year mortality (HR: 1.310, 95% CI: 1.023-1.677). This association was evident among patients who only received chemotherapy or radiotherapy (HR: 1.633, 95% CI: 1.005-2.654).

CONCLUSIONS

Fragmented cancer care was associated with increased risk of five-year mortality. Additionally, changes in the most visited medical institution occurred more frequently in either patients with severe conditions or patients who mainly visited smaller medical institutions. Further study is warranted to confirm these findings and examine a causal relationship between fragmented cancer care and survival.

Human Papillomavirus Vaccination Knowledge, Barriers, and Recommendations Among Healthcare Provider Groups in the Western United States

This study compared human papillomavirus (HPV) vaccination occurrences on the same day as provider recommendations at clinics in the Western United States stratified by healthcare provider groups. In addition, the relationships between provider groups' perceived challenges associated with HPV vaccination, HPV vaccination knowledge, HPV recommendation practices, and same-day HPV vaccinations and recommendations are described. Eligible participants included pediatric healthcare providers and staff with influence on patient/parental-level decisions regarding HPV vaccination. Participants filled out a 40-question survey. Results for study participants (N = 99) showed providers reported a higher number of challenges limiting HPV vaccination, higher HPV vaccination knowledge, and more favorable HPV vaccination recommendation practices compared to other healthcare team members (OTM) suggesting providers may have a better overall understanding of the HPV vaccination climate than OTMs. Clinics should examine OTMs' training, expectations, and opportunities to increase the frequency and strength of HPV vaccination recommendations to adolescent patients and parents.

Before and During Pandemic Telemedicine Use: An Analysis of Rural and Urban Safety-Net Clinics

INTRODUCTION

Differences in face-to-face and telemedicine visits before and during the COVID-19 pandemic among rural and urban safety-net clinic patients were evaluated. In addition, this study investigated whether rural patients were as likely to utilize telemedicine for primary care during the pandemic as urban patients.

METHODS

Using electronic health record data from safety-net clinics, patients aged ≥18 years with ≥1 visit before or during the COVID-19 pandemic, March 1, 2019-March 31, 2021, were identified, and trends in face-to-face and telemedicine (phone and video) visits for patients by rurality using Rural‒Urban Commuting Area codes were characterized. Multilevel mixed-effects regression models compared service delivery method during the pandemic by rurality.

RESULTS

Included patients (N=1,015,722) were seen in 446 safety-net clinics: 83% urban, 10.3% large rural, 4.1% small rural, and 2.6% isolated rural. Before COVID-19, little difference in the percentage of encounters conducted face-to-face versus through telemedicine by rurality was found. Telemedicine visits significantly increased during the pandemic by 27.2 percentage points among patients in isolated rural areas to 52.3 percentage points among patients in urban areas. Rural patients overall had significantly lower odds of using telemedicine for a visit during the pandemic than urban patients.

CONCLUSIONS

Despite the increased use of telemedicine in response to the pandemic, rural patients had significantly fewer telemedicine visits than those in more urban areas. Equitable access to telemedicine will depend on continued reimbursement for telemedicine services, but additional efforts are warranted to improve access to and use of health care among rural patients.

Examining rural-urban disparities in perceived need for health care services among adults with disabilities

Purpose

The purpose of this study is to parse out differences between unmet need and perceived need for health care services among rural and urban adults with disabilities in the United States. While unmet need focuses primarily on environmental factors such as access to health insurance or provider availability, perceived need relates to personal choice. This distinction between unmet and perceived need is largely ignored in prior studies, but relevant to public health strategies to improve access and uptake of preventive care.

Methods

Using Wave 2 data from the National Survey on Health and Disability, we explored rural and urban differences in unmet and perceived health care needs among working-age adults with disabilities for acute and preventive services.

Findings

Although we found no significant differences in unmet needs between rural and urban respondents, we found that perceived needs for dental care and mental health counseling varied significantly across geography. Using logistic regression analysis and controlling for observable participant characteristics, we found that respondents living in noncore counties relative to metropolitan counties were more likely to report not needing dental care (OR 1.89, p = 0.028), and not needing mental health counseling services (OR 2.15, p ≤ 0.001).

Conclusion

These findings suggest additional study is warranted to understand perceived need for preventive services and the levers for addressing rural disparities.

Rural-Urban Disparities in Heart Failure and Acute Myocardial Infarction Hospitalizations

Substantial gaps in clinical outcomes exist in rural and urban hospitals in the United States. We used the National Inpatient Sample to examine trends in hospitalizations, in-hospital mortality, length of stay, and inflation-adjusted cost of adults admitted for heart failure (HF) and acute myocardial infarction (AMI) in rural and urban hospitals between 2004 and 2018. From 2004 to 2013 and 2014, there was an initial decrease in age-adjusted HF hospitalizations in both urban (annual percent change [APC] -3.9 [95% confidence interval [CI] -4.3 to -3.5] p <0.001) and rural hospitals (APC -5.9 [95% CI -6.4 to -5.3] p <0.001), after which hospitalizations for HF increased in urban areas (APC 4.2 [95% CI 3.2 to 5.3] p <0.001) and remained stable in rural areas (APC 0.2 [95% CI -2.1 to 2.6] p = 0.863). Urban AMI hospitalizations decreased between 2004 and 2010 (APC -4.4 [95% CI -5.3 to -3.3] p <0.001) and subsequently remained stable (APC 0.2 [95% CI -0.5 to 0.9] p = 0.552), whereas rural AMI hospitalizations had a consistent decrease throughout the study period (APC -4.2 [95% CI -5.0 to -3.4] p <0.001). Overall, urban hospitals had lower in-hospital mortality for HF and AMI than rural hospitals (3.1% vs 3.5%, p <0.001% and 5.4% vs 6.5%, p <0.001), respectively. Initially, in-hospital mortality was higher in rural hospitals; however, the rural-urban hospital mortality gap decreased during the study period for both HF and AMI. Rural hospitals had a shorter mean length of stay for HF and AMI (4.4 vs 5.5 days, p <0.001 and 3.9 vs 4.7 days, p <0.001) and lower inflation-adjusted costs for both HF and AMI ($8,897.1 vs $13,420.8, p <0.001 and $15,301.6 vs $22,943.7, p <0.001) when compared with urban hospitals. In conclusion, a consistent decrease in the in-hospital mortality gap in rural and urban hospitals for HF and AMI suggests improvement in inpatient rural cardiovascular care during the study period. Continued healthcare policy reforms are warranted to alleviate the disparities in rural-urban cardiovascular outcomes.

System- and Individual-Level Barriers to Accessing Medical Care Services Across the Rural-Urban Spectrum, Washington State

Background:

Residents of rural areas face barriers beyond geography and distance when accessing medical care services. The purpose of this study was to characterize medical care access barriers across several commonly used classifications of rurality.

Methods:

Washington State household residents completed a mixed-mode (paper/online) health care access survey between June 2018 and December 2019 administered to a stratified random sample of ZIP codes classified as urban, suburban, large rural, and small rural (4-tier scheme). For analyses, rurality was also classified into 2-tier schemes (rural/urban) based on ZIP code and county. Respondents reported availability of medical care services and system- and individual-level barriers to accessing services. Logistic regression models estimated the odds of reporting system- or individual-level barriers in accessing medical care services across rurality (4- and 2-tier schemes), adjusting for respondent characteristics, and weighted to account for survey design.

Results:

About 617 households completed the survey (25.7% response rate). Compared to urban residents (across all 3 schemes), more rural residents reported traveling to a distant city or town for medical care (P < .001). Rurality was significantly associated with increased odds of facing system-level barriers. Respondents from small rural areas had greater odds access barriers for primary care (OR 7.31, 95% CI 1.84-29.09) and having no primary care provider (OR 11.37, 95% CI 3.03-42.75) compared to urban respondents. Individual-level barriers were not associated with rurality.

Conclusions:

To improve healthcare access across the rural-urban spectrum, policymakers must consider system-level barriers facing rural populations.

Community relationship quality and reincarceration following rural drug-using women's reentry from jail

Interpersonal relationships and social support are important factors in women's successful reentry from incarceration, but limited research has explored the role of women's relationships to their communities during the reentry process. In the current study, women were recruited from three rural Appalachian jails, screened for high-risk behaviors (including drug use and unprotected sex), and interviewed at 12 months postrelease (N = 339). Interviews included the Relational Health Indices-Community scale, a validated measure of women's relationships in community contexts, with subscales for empowerment/zest, engagement, and authenticity. Women who were reincarcerated during the 12-month postrelease period (43.4%) were younger, less employed, more likely to have used illicit drugs, and reported lower-quality community relationships at 12-month follow-up. Multivariate logistic regression models indicated that the effect of community relationships may be driven by the engagement and empowerment/zest constructs. Results suggest that community connectedness may relate to more successful reentry outcomes for rural women.

Fragmentation of care and colorectal cancer survival in South Korea: comparisons according to treatment at multiple hospitals

PURPOSE

Fragmented cancer care (FC) means that patients visit multiple providers for treatment, which is common in cancer care. While FC is associated with poor health outcomes in patients with colorectal cancer (CRC) worldwide, there is still a lack of evidence in South Korea. We investigated the association between FC and 5-year morality in patients with CRC using population-based claims data.

METHODS

The study population was followed up from 2002 to 2015. Data were collected from Korea National Health Insurance claims. Participants comprised patients with CRC diagnosed with International Classification of Diseases (ICD)-10 (C18.x-C20.x) and a special claim code for cancer (V193). Data were analyzed using the Kaplan-Meier curve with a log-rank test and Cox proportional hazard model. The effect of FC on patients' 5-year survival was examined.

RESULTS

Of 3467 patients with CRC, 20.0% had experienced FC. FC was significantly associated with an increased risk of 5-year mortality (hazard ratio 1.516, 95% confidence interval 1.274-1.804). FC was prevalent in those who had a low income level, underwent chemotherapy, did not undergo radiation therapy, and did not visit a tertiary hospital for their first treatment.

CONCLUSION

Efforts to decrease FC and integrate complex cancer care within appropriate healthcare delivery systems may improve survivorship among patients with CRC.

Influenza Vaccine Utilization: A Comparison between Urban and Rural Counties in Florida

(1) Background: The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) recommend that every person aged six months and over receive the influenza vaccine every year. Previous studies indicate that rural-area residents have less access to preventative health care services. This study aims to examine the variation in influenza vaccine use among rural and urban counties in Florida. (2) Methods: The study studied 24,116 participants from the Behavioral Risk Factor Surveillance System database. The study included only patients who live in Florida. We performed logistic regression analysis using survey procedures available in SAS®. Our regression model assessed the association between receiving the influenza vaccine and county status, age, income level, education level, and health coverage. We used ArcGIS software to create prevalence and vaccination maps. (3) Results: Of the total number of the study participants, 45.31% were residents of rural counties, and 54.69% were residents of urban counties. The logistic regression model showed no significant association between residing in rural counties and not receiving influenza vaccine in the past year (−0.05560, p-value = 0.0549). However, we found significant associations between not receiving influenza vaccine and age, high education level, and not having health care coverage (−0.0412, p-value < 0.0001; −0.04462, p-value = 0.0139; and 0.4956, p-value < 0.0001, respectively). (4)Conclusions: Our study did not find an association between influenza vaccine use among rural and urban residence. Increasing age, higher education, and having health care insurance had positive associations with influenza vaccine use.

Impact of travel burden on clinical outcomes in lung cancer

PURPOSE

Our study explores the influence of travel burden (measured as travel distance and travel time) on clinical outcomes in lung cancer patients.

METHODS

A retrospective analysis of a single Bulgarian center was performed. A total of 9240 lung cancer patients were included in the study. Travel distance and travel time between patients' city of residence and the treating facility were calculated with an online tool to determine the shortest route for travel using the existing road network. The probability of survival was estimated using the Kaplan-Meier method, and differences in survival in each subgroup were evaluated with a log-rank test.

RESULTS

About one third of all included patients were living in the same city as the treating facility (n = 2746, 29.7%). Overall survival in our patient population was significantly lower with increasing travel distance (p < 0.001, Mantel-Cox log rank) and travel time (p < 0.001, Mantel-Cox log rank). The 1-year OS rate according to travel distance was 27.1% in the same city group, 22.4% in < 50-km group, and 20.5% in ≥ 50-km group (p < 0.001). The corresponding values for the 5-year OS rate were 2.9%, 2.6%, and 1.4% (p < 0.001).

CONCLUSION

In this retrospective study, we discovered significant differences in the overall survival of patients with lung cancer depending on travel distance and travel time to the treating oncological facility. Despite having similar clinical and pathological characteristics (age, sex, stage at initial diagnosis, histologic subtype), the median overall survival was significantly lower in those subgroups of patients with a higher travel burden.

Quantifying rural disparity in healthcare utilization in the United States: Analysis of a large midwestern healthcare system

PURPOSE

The objective of this study is to identify how predisposing characteristics, enabling factors, and health needs are jointly and individually associated with epidemiological patterns of outpatient healthcare utilization for patients who already interact and engage with a large healthcare system.

METHODS

We retrospectively analyzed electronic medical record data from 1,423,166 outpatient clinic visits from 474,674 patients in a large healthcare system from June 2018-March 2019. We evaluated patients who exclusively visited rural clinics versus patients who exclusively visited urban clinics using Chi-square tests and the generalized estimating equation Poisson regression methodology. The outcome was healthcare use defined by the number of outpatient visits to clinics within the healthcare system and independent variables included age, gender, race, ethnicity, smoking status, health status, and rural or urban clinic location. Supplementary analyses were conducted observing healthcare use patterns within rural and urban clinics separately and within primary care and specialty clinics separately.

FINDINGS

Patients in rural clinics vs. urban clinics had worse health status [χ2 = 935.1, df = 3, p<0.0001]. Additionally, patients in rural clinics had lower healthcare utilization than patients in urban clinics, adjusting for age, race, ethnicity, gender, smoking, and health status [2.49 vs. 3.18 visits, RR = 0.61, 95%CI = (0.55,0.68), p<0.0001]. Further, patients in rural clinics had lower utilization for both primary care and specialty care visits.

CONCLUSIONS

Within the large healthcare system, patients in rural clinics had lower outpatient healthcare utilization compared to their urban counterparts despite having potentially elevated health needs reflected by a higher number of unique health diagnoses documented in their electronic health records after adjusting for multiple factors. This work can inform future studies exploring the roots and ramifications of rural-urban healthcare utilization differences and rural healthcare disparities.

Prevalence and factors associated with urinary incontinence in women farmers

Abstract Introduction: Urinary incontinence (UI) is any involun-tary loss of urine, exhibiting a relationship with pelvic floor muscle weakness and overload. The physical exertion required of the woman farmer may predispose her to higher frequency of UI. Objective: To evaluate the prevalence of UI and associated factors in women farmers. Methods: Cross-sectional study, with appli-cation of an evaluation form and the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) in women aged between 25 and 50 years old. Women with urinary loss responded to the King's Health Questionnaire (KHQ). Data were collected by individual interview. The data were analyzed by absolute and relative frequency, using the Mann-Whitney test for intergroups and Spearman's Correlation Coefficient to relate the variables, considering p < 0.05. Results: Two hundred farmers were interviewed, where 52 (26%) reported involuntary urine loss. The incontinent group had a higher number of annual urinary infection (3.23 ± 1.40). Most incontinent women reported escape 1x/week or less (73.08%), in small amounts (82.69%), during stress (57.69%). Quality of life was classified as very good by 59.62%. The intensity of the work was considered strong by 25% of the incontinent women. Only 30.5% of the volunteers were able to define UI and 97.7% considered it not normal. Conclusion: The prevalence of UI was equivalent to the average of the female population in general, with urinary infection as an associated factor. The loss occurs mainly to stress, and lack of knowledge can reflect in the identification treatment.

Prevalência e fatores associados à incontinência urinária em agricultoras

Resumo Introdução: Incontinência urinária (IU) é qualquer perda involuntária de urina, apresentando relação com sobrecarga e fraqueza da musculatura do assoalho pélvico. O esforço físico exigido da mulher agricultora pode predispor à maior frequência de IU. Objetivo: Avaliar a prevalência e fatores associados à IU em mulheres agricultoras. Métodos: Estudo de corte transversal, com aplicação de ficha de avaliação e do International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) em mulheres com idade entre 25 e 50 anos. As mulheres com perda urinária responderam ao King’s Health Questionnaire (KHQ). A coleta de dados foi por entrevista individual. Os dados foram analisados por frequência absoluta e relativa, sendo empregado o teste de Mann-Whitney para intergrupos e o coeficiente de correlação de Spearman para relacionar as variáveis, considerando p < 0,05. Resultados: Duzentas mulheres agricultoras foram entrevistadas, das quais 52 (26%) referiram perda involuntária de urina. O grupo incontinente apresentou maior número de infecção urinária anual (3,23 ± 1,40). A maior parte das mulheres incontinentes referiram escape 1x/semana ou menos (73,08%), em pequena quantidade (82,69%) e durante o esforço (57,69%). A qualidade de vida foi classificada como muito boa por 59,62%. A intensidade do trabalho foi considerada forte por 25% das mulheres incontinentes. Apenas 30,5% das voluntárias souberam definir IU a e 97,7% consideram não ser normal. Conclusão: A prevalência de IU foi equivalente à média da população feminina em geral, tendo a infecção urinária como fator associado. A perda ocorre principalmente por conta de esforços e a falta de conhecimento pode dificultar a identificação e procura por tratamento.

An integrative model of patients' perceived value of healthcare service quality in North Cyprus

Background

Improving healthcare quality has become an essential objective for all health institutions worldwide to address the need to improve services, manage costs and satisfy patient expectations about the quality of care. As health is one of the leading service sectors of the North Cyprus economy, analysing patients’ perceived value of healthcare service quality is crucial. In this research, a comparative analysis of existing models revealed affordability, acceptability and accessibility as the leading modern service quality indicators affecting patients’ perceived value of healthcare service quality. The quality of services is a leading factor impacting business competition and retention dictated by the current market. This study aimed to investigate the factors that influence patient perceptions of healthcare service quality in North Cyprus.

Methods

A self-administered questionnaire was carried out among 388 patients of public and private hospitals in North Cyprus, and the data were analysed using partial least squares-structural equation modelling.

Results

Empirical results highlight that the acceptability of healthcare services is a prerequisite for perceiving a high value of service quality. The affordability and accessibility of services, respectively, were less effective. Results concerning mediating effects confirm that acceptability could fully mediate the relationship between affordability and perceived value and could partially mediate the impact of accessibility on the perceived quality of healthcare services.

Conclusion

This study contributes to healthcare theory and practice by developing a conceptual framework to provide policymakers and managers with a practical understanding of factors that affect healthcare service quality.

Trends in Differences Across Subgroups of Adults in Preventive Services Utilization

BACKGROUND

There were large differences across subgroups of adults in preventive services utilization before 2010. The Affordable Care Act had numerous provisions aimed at increasing utilization as well as at reducing disparities.

OBJECTIVE

This study examines whether preventive services utilization changed over time, across subgroups of adults defined by race/ethnicity, insurance coverage, poverty status, Census region, and urbanicity.

METHODS

Data from the Medical Expenditure Panel Survey Household Component are used to examine service utilization before the passage of the Affordable Care Act (2008/2009), after the implementation of the preventive services mandate and the dependent coverage provision (2012/2013), and after Medicaid expansions (2015/2016). Four preventive services are examined for adults aged 19-64-general checkups, blood cholesterol screening, mammograms, and colorectal cancer screening. Multivariate logistic regression models are used to predict preventive services utilization of adult subgroups in each time period, and to examine how differences across subgroups changed between 2008/2009 and 2015/2016.

RESULTS

There were modest increases in utilization between 2008/2009 and 2015/2016 for blood cholesterol and colorectal cancer screenings. For 3 of 4 preventive services, differences between the Northeast and the Midwest regions narrowed. However, large gaps in utilization across income groups and between those with and without coverage persisted. Disparities across racial/ethnic groups in general checkups persisted over time as well.

CONCLUSION

While some differences have narrowed, large gaps in preventive service utilization across population subgroups remain.

Geographic influence on postoperative complications in children with complicated appendicitis: a single center study

Background

Acute appendicitis is one of the most common abdominal emergencies in children. Complicated appendicitis is much more common in pediatric age group than in adults due to probability of delay in diagnosis or misdiagnosis. Geographic status has an influence on the clinical course of such surgical cases. This prospective comparative study was conducted at the pediatric surgery department in our hospital in Egypt during the period from December 2018 to August 2019, aiming to find the relation between residence of patients and occurrence of post-operative complications among patients in Sharkia Governorate, Egypt. Patients were divided into two groups: rural and urban. Data recorded included demographic data, preoperative assessment, operative findings, postoperative course, postoperative complications, and follow-up.

Results

Sixty patients were included in the study, 32 of them were from rural areas, and 28 were from urban areas. There was no significant difference between them regarding demographics. Duration of symptoms was significantly longer with rural group (3.7 ± 1.4 vs. 3.07 ± 0.92 days). Length of hospital stay was significantly longer with the rural group (4.7 ± 1.7 vs. 4.7 ± 1.7 days). The rate of wound infection was significantly higher with the rural group (34.37% vs. 10.7%), while other postoperative complications were increased with rural group, but that was not statistically significant. The regularity of follow-up was higher with the urban group.

Conclusions

Children with complicated appendicitis from rural areas are at higher risk for occurrence of postoperative complications and poor outcome, with less regularity in follow-up. This is because of many obstacles they faced, including difficulties of transportation, insufficient medical services, and low socioeconomic and educational statuses.

Successful Multi-Level HPV Vaccination Intervention at a Rural Healthcare Center in the Era of COVID-19

Objectives: To develop and test a human papillomavirus (HPV) vaccination intervention that includes healthcare team training activities and patient reminders to reduce missed opportunities and improves the rate of appointment scheduling for HPV vaccination in a rural medical clinic in the United States.

Methods: The multi-level and multi-component intervention included healthcare team training activities and the distribution of patient education materials along with technology-based patient HPV vaccination reminders for parents/caregivers and young adult patients. Missed vaccination opportunities were assessed pre- and post-intervention (n = 402 and n = 99, respectively) by retrospective chart review and compared using Pearson χ². The patient parent/caregiver and young adult patient population (n = 80) was surveyed following the reminder messages and penalized logistic regression quantified unadjusted odds of scheduling a visit.

Results: Missed opportunities for HPV vaccination declined significantly from the pre-intervention to the post-intervention period (21.6 vs. 8.1%, respectively, p = 0.002). Participants who recalled receipt of a vaccination reminder had 7.0 (95% CI 2.4–22.8) times higher unadjusted odds of scheduling a visit compared with those who did not recall receiving a reminder. The unadjusted odds of confirming that they had scheduled or were intending to schedule a follow-up appointment to receive the HPV vaccine was 4.9 (95% CI 1.51–20.59) times greater among those who had not received the vaccine for themselves or for their child.

Conclusions: Results from this intervention are promising and suggest that vaccination interventions consisting of provider and support staff education and parent/caregiver and patient education materials, and reminders can reduce missed opportunities for vaccinations in rural settings.

Rural-urban differences in HPV testing for cervical cancer screening

PURPOSE

Rural preventable cancer disparities are often attributed in part to lower screening rates secondary to compromised health care access. When considering higher cervical cancer incidence and mortality, existing analyses primarily consider differences in Pap testing rather than the preferred method of HPV testing, which is more sensitive in identifying severe cases of cervical dysplasia.

METHODS

Logistic regression using data from the 2016 and 2018 Behavioral Risk Factor Surveillance System was used to examine urban and rural rates of cervical cancer screening according to national guidelines. Propensity score weighting was used to account for baseline sociodemographic differences between rural and urban populations in the 2016 landline sample.

FINDINGS

In 2016 and 2018, rural women were less likely than urban women to have current cervical cancer screening. This disparity was explained by sociodemographic variables in 2016. Among women with current cervical cancer screening, rural women were significantly less likely than urban women to undergo HPV testing in both 2016 and 2018.

CONCLUSION

Rural women with current cervical cancer screening were significantly less likely than their urban counterparts to have HPV testing. It is possible that updates to preventive care guidelines may be slower to reach rural providers, rural patients may be unaware that HPV testing was completed, or rural practice configuration may complicate the integration of HPV testing into clinical practice. Failure to undergo HPV testing may lead to delayed cervical dysplasia diagnosis, missed opportunities for early intervention, and contribute to rural/urban disparities in cervical cancer incidence and mortality.

Geographic Distributions of Drag Performers Relative to Urban Centers: Implications for Health

LGB people may become less accessible to health professionals as technology reshapes LGB social connections. Though electronic forms of health promotion are effective, some interventions must be delivered in person. We use GIS to analyze characteristics (e.g., gender identity, depression, and performance involvement) shared by 114 gay, cisgender male drag performers. We used geographic ordinary least squares (OLS) regression to identify spatial relationships based on participant distance from urban centers. Participants lived between 1.73 km (1.07 mi) and 762.77 km (101.14 mi) from the nearest urban center (Mdn = 16.60 km; 10.31 mi). We found a positive correlation between distance from the nearest urban center and performance involvement (R = 0.19, p ≤ 0.05). Results indicate that drag performers are widely disbursed relative to urban centers and that drag involvement provides motivation to travel to gay bars. Health professionals with in person services may use drag shows and related performances to access LGB populations.

Policy liberalism and source of news predict pandemic-related health behaviors and trust in the scientific community

In March of 2020, the United States was confronted with a major public health crisis caused by the coronavirus disease (COVID-19). This study aimed to identify what factors influence adherence to recently implemented public health measures such as mask-wearing and social distancing, trust of scientific organizations like the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) on information pertaining to the pandemic, and level of perceived risk. Data were collected from June 30, 2020 to July 22, 2020 on 951 adult residents of the United States using an online survey through Microsoft Forms. Multiple linear regression was used to identify the strongest predictors for compliance to pandemic-related health measures, trust in the scientific community, and perceived risk. Results showed that the strongest predictor of all variables of interest was degree of policy liberalism. Additionally, participants who consumed more conservative news media conformed less to the pandemic health guidelines and had less trust in the scientific community. Degree of policy liberalism was found to have a significant moderating effect on the relationship between gender and conformity to pandemic-related health behaviors. These findings have concerning implications that factors like degree of policy liberalism and source of news are more influential in predicting adherence to life-saving health measures than established risk factors like pre-existing health conditions.

Measurement of urinary pesticide biomarkers among Latina farmworkers in southwestern Idaho

BACKGROUND

Women who work in agriculture may have greater risk of pesticide exposure than men who share this occupation. Despite an increase in the fraction of the agricultural workforce comprised by women, few studies have characterized pesticide exposure in the USA with a focus on among these workers.

OBJECTIVE

This pilot study aimed to describe pesticide exposure in a cohort of Latina farmworkers in farming communities in southwestern Idaho.

METHODS

We collected urine samples from 29 Latina farmworkers, which were analyzed for 11 pesticide biomarkers. We evaluated the effect of pesticide spray season on urinary biomarker levels, and explored the effect of self-reported status as a pesticide handler on measured exposures.

RESULTS

No significant differences were found between biomarker levels in samples collected during the nonspray and spray seasons. We observed 11 extreme outlying values in samples collected during the pesticide spray season. The most extreme outlying values (MDA: 51.7 ng/mL; 3-PBA: 11.8 ng/mL; trans-DCCA: 23.4 ng/mL; and 2,4-D: 31.1 ng/mL) were all provided during the spray season by women who reported loading, mixing or applying pesticides.

CONCLUSIONS

These results provide suggestive evidence that Latina farmworkers who handle pesticides during the spray season may be at an increased risk of exposure to organophosphate and pyrethroid insecticides, as well as the herbicide 2,4-D. We recommend that future research into pesticide exposures among farmworkers should include particular focus on this group.

The influence of individual and neighborhood-level characteristics on rural-urban disparities in cardiovascular disease mortality among U.S. women diagnosed with breast and gynecologic cancers

OBJECTIVE

Rural-urban disparities exist in cancer and cardiovascular disease (CVD) mortality. Investigations of CVD mortality among breast and gynecologic cancer (BGC) survivors from rural/urban communities are limited. We evaluated the influence of individual and neighborhood-level factors on rural-urban disparities in CVD mortality among BGC survivors.

METHODS

Data were from 1,139,767 women aged ≥20 years from the Surveillance, Epidemiology, and End Results program who were diagnosed with BGC from 2000 to 2016 that was merged with Area Health Resource Files for neighborhood-level factors (smoking, cancer screening, primary care provider density and socioeconomic index). Standardized mortality ratios (SMRs) for CVD mortality were calculated and multilevel Cox models, accounting for competing events, were used to estimate hazards ratios (HR) and 95% confidence intervals (CI).

RESULTS

The average age of BGC survivors was 60 years, with 10.3% of them living in rural counties. During a median follow-up of 5.1 years, 47,995 CVD deaths occured. Women with BGC had excess CVD mortality compared to general population women (SMR 6.05; CI: 6.00-6.11). This risk was highest among women aged <50 years (SMR = 27.16; CI: 25.74-28.62). In models adjusted for demographics, cancer stage and cancer therapy, women with BGC in rural communities had higher CVD deaths than those in urban communities (HR = 1.10, CI:1. 05-1.15). Additional adjustment for neighborhood-level characteristics attenuated the relation of rurality with CVD mortality (HR = 1.02, CI: 0.98-1.07).

CONCLUSIONS

BGC survivors living in rural communities have elevated risk of CVD mortality. Neighborhood-level characteristics explained the rural-urban disparities in CVD mortality observed among BGC survivors.

Systematic scoping review of factors and measures of rurality: toward the development of a rurality index for health care research in Japan

BACKGROUND

Rural-urban health care disparities are an important topic in health services research. Hence, developing valid and reliable tools to measure rurality is needed to support high quality research. However, Japan, has no index to measure rurality for health care research. In this study, we conducted a systematic scoping review to identify the important factors and methodological approaches to consider in a rurality index to inform the development of a rurality index for Japan.

METHODS

For our review, we searched six bibliographic databases (MEDLINE, PubMed, CINAHIL, ERIC, Web of Science and the Grey Literature Report) and official websites of national governments such as Government and Legislative Libraries Online Publications Portal (GALLOP), from 1 January 1989 to 31 December 2018. We extracted relevant variables used in the development of rurality indices, the formulas used to calculate indices, and any measures for reliability and validity of these indices.

RESULTS

We identified 17 rurality indices from 7 countries. These indices were primarily developed to assess access to health care or to determine eligibility for incentives for health care providers. Frequently used factors in these indices included population size/density and travel distance/time to emergency care or referral centre. Many indices did not report reliability or validity measures.

CONCLUSIONS

While the concept of rurality and concerns about barriers to access to care for rural residents is shared by many countries, the operationalization of rurality is highly context-specific, with few universal measures or approaches to constructing a rurality index. The results will be helpful in the development of a rurality index in Japan and in other countries.

Synthetic Pesticides and Health in Vulnerable Populations: Agricultural Workers

PURPOSE OF REVIEW

This review aims to summarize epidemiological literature published between May 15, 2018, and May 14, 2019, that examines the relationship between exposure to synthetic pesticides and health of agricultural workers.

RECENT FINDINGS

Current research suggests that exposure to synthetic pesticides may be associated with adverse health outcomes. Agricultural workers represent a potentially vulnerable population, due to a combination of unique social and cultural risk factors as well as exposure to hazards inherent in agricultural work. Pesticide exposure among agricultural workers has been linked to certain cancers, DNA damage, oxidative stress, neurological disorders, and respiratory, metabolic, and thyroid effects. This review describes literature suggesting that agricultural workers exposed to synthetic pesticides are at an increased risk of certain cancers and neurological disorders. Recent research on respiratory effects is sparse, and more research is warranted regarding DNA damage, oxidative stress, metabolic outcomes, and thyroid effects.

Predictors of Receipt of Clinical Preventive Services in Adolescents and Adults with Down Syndrome Accessing Medicaid

BACKGROUND

Persons with Down syndrome (DS) require preventive care that addresses their age-/gender- and syndrome-specific needs. Yet, adolescents and adults with DS do not receive these preventive care services as recommended.

OBJECTIVE/HYPOTHESIS

To identify factors that predict receipt of age-/gender- and syndrome-specific preventive healthcare among adolescents and adults with DS. We hypothesized that more healthcare encounters and greater medical complexity would increase receipt of preventive care due to more opportunities to complete these activities.

METHODS

Using Medicaid claims (2006-2010) for California, Colorado, Michigan, and Pennsylvania, we conducted a retrospective cohort study of adolescents and adults with DS (≥12 years old). We modeled receipt of both ≥1 wellness examination and ≥1 thyroid function test (TFT) in 2009-2010 as a function of receipt of those same healthcare activities in 2006-08, adjusting for demographics, key comorbidities, and medical complexity using multivariable logistic regression.

RESULTS

In this cohort of 3487 adolescents and adults with DS accessing Medicaid, 17% received both ≥1 wellness examination and ≥1 TFT in 2006-2008, 15% in 2009-2010, and only 7% during both time periods. Despite medical complexity and frequent healthcare interactions, the best predictor of future receipt of these activities was past receipt. State of residence variably impacted receipt of these preventive activities.

CONCLUSIONS

Although past receipt of wellness examination and TFT was the best predictor of future receipt of these activities, overall rates were quite low in this cohort of adolescents and adults with DS. Further work is needed to improve preventive healthcare delivery to this vulnerable population.