Health status and access to care among rural minorities

Rural-Urban Health Care Cost Differences Among Latinx Adults With and Without Dementia in the United States

OBJECTIVES

To compare rural-urban health care costs among Latinx adults ages 51+ and examine variations by dementia status.

METHODS

Data are from the Health and Retirement Study (2006-2018 waves; n = 15,567). We inflation-adjusted all health care costs using the 2021 consumer price index. Geographic context and dementia status were the main exposure variables. We applied multivariate two-part generalized linear models and adjusted for sociodemographic and health characteristics.

RESULTS

Rural residents had higher total health care costs, regardless of dementia status. Total health care costs were $850 higher in rural ($2,640) compared to urban ($1,789) areas (p < .001). Out-of-pocket costs were $870 higher in rural ($2,677) compared to urban ($1,806) areas (p < .001). Dementia status was not an effect modifier.

DISCUSSION

Health care costs are disproportionately higher among Latinx rural, relative to urban, residents. Addressing health care costs among Latinx rural residents is a public health priority.

Rural Latino Men’s Experiences and Attitudes Toward Health: A Pilot Photovoice Study

Much of the research regarding Latino men’s health tends to focus on specific health outcomes (e.g., HIV or diabetes). Few studies have examined how Latino men perceive factors that influence their health and/or health-related behaviors. This study explored rural Latino men’s experiences and attitudes toward health, using photovoice, in the context of a community-based participatory research partnership. We recruited nine Latino men living in a small town in Southeastern Iowa. Four to nine men attended four sessions and led a community forum. All the men were foreign-born, identified as Latino, aged between 34 and 67 years, and had lived in the United States for at least 7 years. Five themes were identified: (a) cultural conflict, (b) too much and discordant information, (c) lifestyles conflict, (d) sacrifice, and (e) family connectedness. An important implication of this study derives from familial and community connections and sacrifice. Feeling disconnected from family may impact physical and mental health and health-promoting behaviors. Future research should explore ways to inform community- and family-level interventions to connect rural Latino men more strongly to their family and local community and help them to take better control of their health.

Environmental justice and allergic disease: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee and the Diversity, Equity and Inclusion Committee

Environmental justice is the concept that all people have the right to live in a healthy environment, to be protected against environmental hazards, and to participate in decisions affecting their communities. Communities of color and low-income populations live, work, and play in environments with disproportionate exposure to hazards associated with allergic disease. This unequal distribution of hazards has contributed to health disparities and is largely the result of systemic racism that promotes segregation of neighborhoods, disinvestment in predominantly racial/ethnic minority neighborhoods, and discriminatory housing, employment, and lending practices. The AAAAI Environmental Exposure and Respiratory Health Committee and Diversity, Equity and Inclusion Committee jointly developed this report to improve allergy/immunology specialists' awareness of environmental injustice, its roots in systemic racism, and its impact on health disparities in allergic disease. We present evidence supporting the relationship between exposure to environmental hazards, particularly at the neighborhood level, and the disproportionately high incidence and poor outcomes from allergic diseases in marginalized populations. Achieving environmental justice requires investment in at-risk communities to increase access to safe housing, clean air and water, employment opportunities, education, nutrition, and health care. Through policies that promote environmental justice, we can achieve greater health equity in allergic disease.

Disparities in Spatial Access to Emergency Surgical Services in the US

Importance

Hospitals with emergency surgical services provide essential care for a wide range of time-sensitive diseases. Commonly used measures of spatial access, such as distance or travel time, have been shown to underestimate disparities compared with more comprehensive metrics.

Objective

To examine population-level differences in spatial access to hospitals with emergency surgical capability across the US using enhanced 2-step floating catchment (E2SFCA) methods.

Design, Setting, and Participants

A cross-sectional study using the 2015 American Community Survey data. National census block group (CBG) data on community characteristics were paired with geographic coordinates of hospitals with emergency departments and inpatient surgical services, and hospitals with advanced clinical resources were identified. Spatial access was measured using the spatial access ratio (SPAR), an E2SFCA method that captures distance to hospital, population demand, and hospital capacity. Small area analyses were conducted to assess both the population with low access to care and community characteristics associated with low spatial access. Data analysis occurred from February 2021 to July 2022.

Main Outcomes and Measures

Low spatial access was defined by SPAR greater than 1.0 SD below the national mean (SPAR <0.3).

Results

In the 217 663 CBGs (median [IQR] age for CBGs, 39.7 [33.7-46.3] years), there were 3853 hospitals with emergency surgical capabilities and 1066 (27.7%) with advanced clinical resources. Of 320 million residents, 30.8 million (9.6%) experienced low access to any hospital with emergency surgical services, and 82.6 million (25.8%) to advanced-resource centers. Insurance status was associated with low access to care across all settings (public insurance: adjusted rate ratio [aRR], 1.21; 95% CI, 1.12-1.25; uninsured aRR, 1.58; 95% CI, 1.52-1.64). In micropolitan and rural areas, high-share (>75th percentile) Hispanic and other (Asian; American Indian, Alaska Native, or Pacific Islander; and 2 or more racial and ethnic minority groups) communities were also associated with low access. Similar patterns were seen in access to advanced-resource hospitals, but with more pronounced racial and ethnic disparities.

Conclusions and Relevance

In this cross-sectional study of access to surgical care, nearly 1 in 10 US residents experienced low spatial access to any hospital with emergency surgical services, and 1 in 4 had low access to hospitals with advanced clinical resources. Communities with high rates of uninsured or publicly insured residents and racial and ethnic minority communities in micropolitan and rural areas experienced the greatest risk of limited access to emergency surgical care. These findings support the use of E2SFCA models in identifying areas with low spatial access to surgical care and in guiding health system development.

Disparities in Health Care Access and Utilization at the Intersections of Urbanicity and Sexual Identity in California

Purpose: The aim was to examine differences in health care access at the intersections of urbanicity and sexual identity in California. Methods: We used the 2014-2017 Adult California Health Interview Survey paired with the sexual orientation special use research file to create dummy groups representing each dimension of urbanicity and sexual identity to compare access to health care outcomes. We calculated unadjusted proportions and estimated adjusted odds ratios of each dimension relative to urban heterosexual people using logistic regressions. Results: Relative to urban heterosexual people, urban gay/lesbian people had 1.651 odds of using the emergency room (ER). Urban bisexual people had 1.429 odds of being uninsured, 1.575 odds of delaying prescriptions, and 1.907 odds of using the ER. Rural bisexual people experienced similar access barriers having 1.904 odds of uninsurance and 2.571 odds of using the ER. Conclusions: Our study findings demonstrated disparate access to health care across sexual orientation and rurality. The findings are consistent with literature that suggests urban and rural sexual minority people experience health care differently and demonstrate that bisexual people experience health care differently than gay/lesbian people. These findings warrant further study to examine how social identities, such as race/ethnicity, interact with sexual orientation to determine health care access. Furthermore, these findings demonstrate the need to emphasize the health care access needs of sexual minority people in both rural and urban areas to eliminate health care access disparities.

Household Registration System, Migration, and Inequity in Healthcare Access

This study investigates the influence of the household registration system on rural–urban disparity in healthcare access (including healthcare quality, blood pressure check, blood test, vision test, dental examination, and breast exam), using data from a large-scale nationwide life history survey that covered 150 counties across 28 provinces and municipalities in China. In contrast to the findings of many previous studies that emphasize the disparity in the residence place as the cause of rural–urban disparity in healthcare access, this study finds that the residence place just has a very limited influence on healthcare access in China, and what really matters is the household registration type. Our empirical results show that people with a non-rural household registration type generally have better healthcare access than those with a rural one. For rural residents, changing the registration type of their household (from rural to non-rural) can improve their healthcare access, whereas changing the residence place or migrating from rural to urban areas have no effect. Therefore, mere rural-to-urban migration may not be a valid measure to eliminate the rural–urban disparity in healthcare access, unless the institution of healthcare resource allocation is reformed.

The Health Beliefs of Migrant Farmworker Parents: An Ethnographic Exploration

The purpose of this study was to explore the health beliefs of migrant farmworkers parents by approaching and interviewing the sample population in a health clinic where they seek care for their children. It is impossible to plan, implement care, or create health care delivery models without knowledge of health beliefs. An understanding of parental health beliefs in the vulnerable population of migrant farmworkers will assure a more informed approach to health matters of their children, while also improving health care delivery and providing culturally specific health care models. Collecting data in locations historically proven to generate trust and respect supported the objectives of this research study and promoted direct engagement with a group that is often misunderstood and marginalized. Twenty migrant farmworkers parents were interviewed during growing season in the largely agricultural setting of Weld County, Colorado. Associated variables/phenomena determining health beliefs include parental decision-making regarding children's health maintenance, injury prevention, and health care. The overarching theme that emerged from the data was pride in having healthy children with major themes of respect, convenience and inhibition/suppression.

Racial/Ethnic Health Disparities Among Rural Adults - United States, 2012-2015

PROBLEM/CONDITION

Rural communities often have worse health outcomes, have less access to care, and are less diverse than urban communities. Much of the research on rural health disparities examines disparities between rural and urban communities, with fewer studies on disparities within rural communities. This report provides an overview of racial/ethnic health disparities for selected indicators in rural areas of the United States.

REPORTING PERIOD

2012-2015.

DESCRIPTION OF SYSTEM

Self-reported data from the 2012-2015 Behavioral Risk Factor Surveillance System were pooled to evaluate racial/ethnic disparities in health, access to care, and health-related behaviors among rural residents in all 50 states and the District of Columbia. Using the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties to assess rurality, this analysis focused on adults living in noncore (rural) counties.

RESULTS

Racial/ethnic minorities who lived in rural areas were younger (more often in the youngest age group) than non-Hispanic whites. Except for Asians and Native Hawaiians and other Pacific Islanders (combined in the analysis), more racial/ethnic minorities (compared with non-Hispanic whites) reported their health as fair or poor, that they had obesity, and that they were unable to see a physician in the past 12 months because of cost. All racial/ethnic minority populations were less likely than non-Hispanic whites to report having a personal health care provider. Non-Hispanic whites had the highest estimated prevalence of binge drinking in the past 30 days.

INTERPRETATION

Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data. This study revealed difficulties among non-Hispanic whites as well, primarily related to health-related risk behaviors. Across each population, the challenges vary.

PUBLIC HEALTH ACTION

Stratifying data by different demographics, using community health needs assessments, and adopting and implementing the National Culturally and Linguistically Appropriate Services Standards can help rural communities identify disparities and develop effective initiatives to eliminate them, which aligns with a Healthy People 2020 overarching goal: achieving health equity.

Intersection of Living in a Rural Versus Urban Area and Race/Ethnicity in Explaining Access to Health Care in the United States

OBJECTIVES

To examine whether living in a rural versus urban area differentially exposes populations to social conditions associated with disparities in access to health care.

METHODS

We linked Medical Expenditure Panel Survey (2005-2010) data to geographic data from the American Community Survey (2005-2009) and Area Health Resource File (2010). We categorized census tracts as rural and urban by using the Rural-Urban Commuting Area Codes. Respondent sample sizes ranged from 49 839 to 105 306. Outcomes were access to a usual source of health care, cholesterol screening, cervical screening, dental visit within recommended intervals, and health care needs met.

RESULTS

African Americans in rural areas had lower odds of cholesterol screening (odds ratio[OR] = 0.37; 95% confidence interval[CI] = 0.25, 0.57) and cervical screening (OR = 0.48; 95% CI = 0.29, 0.80) than African Americans in urban areas. Whites had fewer screenings and dental visits in rural versus urban areas. There were mixed results for which racial/ethnic group had better access.

CONCLUSIONS

Rural status confers additional disadvantage for most of the health care use measures, independently of poverty and health care supply.

Access to Care and Diabetes Management Among Older American Indians With Type 2 Diabetes

OBJECTIVE

To examine the relationship between health care access and diabetes management among a geographically diverse sample of American Indians (AIs) aged 50 and older with type 2 diabetes.

METHOD

We examined the relationship between access to care and diabetes management, as measured by HbA_1c, using 1998-1999 data from the Strong Heart Family Study. A series of bivariate and multivariate linear models examined the relationships between nine access-related variables and HbA_1c levels.

RESULTS

In bivariate analyses, out-of-pocket costs were associated with higher HbA_1c levels. No other access-related characteristics were significantly associated with diabetes management in bivariate or in multivariate models.

DISCUSSION

Access-related barriers were not associated with worse diabetes management in multivariate analyses. The study concludes with implications for clinicians working with AI populations to enhance opportunities for diabetes management.

Mental Health, Racial Discrimination, and Tobacco Use Differences Across Rural-Urban California

OBJECTIVE

Disparities in tobacco use persist despite successful policies reducing use within the United States. In particular, the prevalence of tobacco use in rural and certain minority communities is significantly higher compared to that of their counterparts. In this work, we examine the impact of rurality, mental health, and racial discrimination on tobacco use.

METHODS

Data come from the 2003 California Health Interview Survey (n = 42,044). Modified Poisson regression models were adjusted for age, sex, race/ethnicity, birth origin, education, income, insurance, and marital status.

RESULTS

Compared to urban residents, rural residents had a significantly higher risk for smoking after adjustment (RR = 1.10, 95% CI: 1.01-1.19). Those who reported having experienced racial discrimination also had a significantly greater risk for smoking compared to those who did not (RR = 1.17, 95% CI: 1.07-1.27). Additionally, those who reported higher stress had a significantly greater risk for smoking (RR = 1.61, 95% CI: 1.07-1.67). There was evidence of interaction between rurality and race/ethnicity, and rurality and gender (P < .05).

CONCLUSION

Residing in rural areas was associated with an increased risk for smoking, above and beyond sociodemographics. There were no significant differences across rural-urban environments for the relationship between stress and tobacco use-an indication that the impact of stress and discrimination is not buffered or exacerbated by environmental characteristics potentially found in either location. Mechanisms that explain rural-urban tobacco use disparities need to be explored, and smoking cessation programs and policies should be tailored to target these factors within rural communities.

Health Care Access, Utilization, and Management in Adult Chinese, Koreans, and Vietnamese with Cardiovascular Disease and Hypertension

BACKGROUND

Asians are often pooled together when evaluating disparities in health care indicators (access, utilization, and management), though substantial variation may exist across different Asian ethnicities.

OBJECTIVE

The aim of this study was to compare health care indicators among Chinese, Korean, Vietnamese, and non-Hispanic white (NHW) adults with cardiovascular disease and hypertension (CVD/HTN).

METHODS

We analyzed health care indicators using multivariable logistic regression in a sample of Asians and NHWs with CVD/HTN from the 2011-2012 California Health Interview Survey (CHIS).

RESULTS

Koreans had the lowest utilization of emergency room (ER) or inpatient hospital services; Vietnamese had the lowest access to a personal doctor; Chinese had the lowest adjusted odds of having seen a doctor in the prior 12 months; and all Asians received fewer written heart disease care plans compared to NHWs. Even when utilization of ER for heart disease appeared to be similar, lack of access to a doctor was a more common reason noted by Asians versus NHWs. However, a lower proportion of Asians reported delays in receiving prescription or care. Accounting for differences across groups did not diminish these disparities.

CONCLUSION

Health care indicators varied by race and across Asian ethnicities even after controlling for sociodemographic factors, insurance coverage, and health status. Future studies should consider oversampling other Asian ethnicities and assessing more in depth the potential impact of ethnicity-related factors on disparities in health care indicators.

Rural-urban differences in acute myocardial infarction mortality: Evidence from Nebraska

AIMS

Acute myocardial infarction (AMI) remains a major cause of death and disability in the United States and worldwide. Despite the importance of surveillance and secondary prevention, the incidence of and mortality from AMI are not continuously monitored, and little is known about survival outcomes after 30 days of AMI hospitalization or associated risk factors, especially in the rural areas. The current study examines rural-urban differences in both in- and out-hospital survival outcomes for AMI patients.

METHODS

We performed a retrospective analysis using hospital discharge data in Nebraska for January 2005 to December 2009 and Nebraska death certificate records through October 2011. Multivariate logistic regression was used to estimate the rural-urban difference in 30-day mortality. A Cox proportional hazard model was used to predict out-of-hospital and overall survival rate.

RESULTS

In the 30-day mortality model, after controlling for age, comorbidities, and rehabilitation, patients in urban areas were less likely to die than patients in rural areas (odds ratio: 0.709, 95% confidence interval: 0.626-0.802). In the overall survival model, patients in urban areas had a lower hazard of AMI death (hazard ratio: 0.86, 95% confidence interval: 0.806-0.931) than patients in rural areas. Patients with a previous history of heart failure had a significantly higher likelihood of 30-day mortality, while atrial fibrillation, heart failure, and chronic kidney disease were associated with lower overall survival. Patients who attended at least 1 cardiac rehabilitation session had significantly lower 30-day and overall mortality (p < 0.0001).

CONCLUSIONS

This study confirms previous findings on rural-urban disparities in 30-day mortality following AMI hospitalization, and reports new findings on overall rural-urban mortality disparity. The study also found an association between cardiac rehabilitation and reduced mortality, a finding never before reported at the population level. Further efforts are needed to develop systems in rural hospitals and communities to ensure that AMI patients receive recommended care.

Diabetes self-management activities for Latinos living in non-metropolitan rural communities: a snapshot of an underserved rural state

The Latino community continues to grow in the rural Midwest, and diabetes is a pertinent disease for research in this demographic. Patient self-management is an important aspect of comprehensive care for diabetes and may mitigate complications. A cross-sectional survey assessed various activities including self-monitoring of blood glucose, personal foot inspection, diet adherence, and diabetes self-management education. Less than half of the sample performed self-monitoring of blood glucose daily (40 %), adhered strictly to special diabetes diet recommendations (44 %), or attended a diabetes self-management education class (48 %). Participants advised on personal foot inspection were three times more likely to perform the self-care activity. Improvements are indicated in these self-management activities. Further research is needed to discern disparities and barriers in self-monitoring of blood glucose among this target population. An increased emphasis on enrollment in diabetes self-management classes should target foreign-born Latinos with lower levels of education.

Lived Challenges and Getting Through Them

Because of imposed rapid social change, Alaska Native youth are growing up in a context different from their elders and suffering far worse health and behavioral outcomes. This research seeks to understand (a) their everyday struggles and life challenges, (b) the practices and resources they rely on to get through challenges, and (c) the meaning they make from these experiences. Data were generated from interviews with 20 Alaska Native youth between the ages of 11 and 18 years, balanced by gender and age-group (early and late adolescence). Purposive sampling identified participants with a broad range of experiences. Following a semistructured guide, youth participated in face-to-face, audio-recorded interviews, transcribed verbatim. A codebook was developed using an iterative process and transcripts were coded using ATLAS.ti. The most commonly identified stressors were relationship loss, “not being there for me,” nonsupportive/hostile experiences, transitioning into adulthood, and boredom. Resilience strategies included developing and maintaining relationships with others, being responsible, creating systems of reciprocity, practicing subsistence living, and giving back to family and the community. These opportunities allowed youth to gain a sense of competence and mastery. When difficult experiences align with opportunities for being responsible and competent, youth are most likely to exhibit resilience.

Disparity surveillance of nonfatal motor vehicle crash injuries

OBJECTIVE

The lack of race information for nonfatal motor vehicle crash injuries in the United States has limited the understanding of racial disparities in motor vehicle crashes (MVCs). In this article, we describe a pilot surveillance project in Nebraska that linked crash reports and driver's license records to investigate racial disparity among nonfatal MVC injuries.

METHODS

The project linked 43,157 severely and nonseverely injured drivers from crash reports between 2006 and 2010 to the corresponding state driver's license database so that drivers' race information from each MVC could be retrieved. A log rate model was used to examine the likelihood of MVC injuries by drivers' race along the dimensions of age, sex, and place of residence.

RESULTS

Black drivers had 31.6 and 87 percent more severe and nonsevere injuries, respectively, than white drivers. Rural residents were more likely than urban residents to have severe MVC injuries. Controlling for residence status, age, and sex did not alter the basic pattern that black drivers had higher rates of nonfatal MVC injuries.

CONCLUSIONS

The linkage approach provides an effective way to obtain additional information for MVC injury disparity surveillance. To reduce racial disparities in severe and nonsevere MVC injuries, race-sex-, race-age-, and race-location-specific interventions should be considered based on their significant contributions to disparity.

Urban-rural differences in attitudes and practices toward long-acting reversible contraceptives among family planning providers in Texas

BACKGROUND

Despite the elevated rates of teen and unplanned pregnancies across the United States, long-acting reversible contraceptives (LARCs) remain a less utilized birth control method. The present study investigated family planning providers' attitudes and considerations when recommending family planning methods and LARCs to clients. Additionally, this study explored whether urban-rural differences exist in providers' attitudes toward LARCs and in clients' use of LARCs.

METHODS

Data were collected using an online survey of family planning providers at Title X clinics in Texas. Survey data was linked to family planning client data from the Family Planning Annual Report (2008).

RESULTS

Findings indicated that, although providers were aware of the advantages of LARCs, clients' LARC use remains infrequent. Providers reported that the benefits of hormone implants include their effectiveness for 3 years and that they are an option for women who cannot take estrogen-based birth control. Providers acknowledged the benefits of several types of LARCs; however, urban providers were more likely to acknowledge the benefits of hormone implants compared with their rural counterparts. Results also indicated barriers to recommending LARCs, such as providers' misinformation about LARCs and their caution in recommending LARCs to adolescents. However, findings also indicated providers lack training in LARC insertion, specifically among those practicing in rural areas.

CONCLUSIONS

In light of the effectiveness and longevity of LARCs, teenagers and clients living in rural areas are ideal LARC candidates. Increased training among family planning providers, especially for those practicing in rural areas, may increase their recommendations of LARCs to clients.

Decreasing hospitalization and in-hospital mortality related to cholangitis in the United States

OBJECTIVES

The aim of this study was to determine trends in hospitalization rates and in-hospital mortality of cholangitis and also determine predictive factors of in-hospital mortality.

METHODS

The Nationwide Inpatient Sample database was utilized for inpatient data analysis from 1988 to 2006. Patients with primary cholangitis International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) discharge diagnosis were included. Age-adjusted procedure rates for endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement and sphincterotomy were also analyzed. Analysis of variance was used to evaluate trends, and linear Poisson multivariate regression model was used to control for variations in age, sex, time of diagnosis, and ethnicity. Logistic regression analysis was performed to determine predictive factors of in-hospital mortality.

RESULTS

The age-adjusted hospitalization rate of cholangitis decreased 24.8% from 2.34 per 100,000 in 1988 to 1.76 per 100,000 in 2006 (P < 0.01). The age-adjusted in-hospital mortality of cholangitis increased 9.2% from 165.0 to 181.6 per 100,000 from 1988 to 1998 (P < 0.01), and then declined 73% to 48.9 per 100,000 in 2006 (P < 0.01). The age-adjusted procedure rates for ERCP with biliary stenting increased from 0.55 to 15.23 per 100,000 from 1988 to 2006 (P < 0.01), as did the age-adjusted rates for ERCP with sphincterotomy from 1.06 to 35.64 per 100,000 (P < 0.01).

CONCLUSIONS

The hospitalization rate of cholangitis has been declining over the past 2 decades. The overall trend in mortality peaked in 1998 and has shown a subsequent decline that may in part be related to increased utilization of endoscopic biliary decompression.

Cancer Screening Delivery in Persistent Poverty Rural Counties

Background: Rural populations are diagnosed with cancer at different rate and stages than nonrural populations, and race/ethnicity as well as the area-level income exacerbates the differences. The purpose of this analysis was to explore cancer screening rates across persistent poverty rural counties, with emphasis on nonwhite populations. Methods: The 2008 Behavioral Risk Factor Surveillance System was used, combined with data from the Area Resource File (analytic n = 309 937 unweighted, 196 344 347 weighted). Unadjusted analysis estimated screening rates for breast, cervical, and colorectal cancer. Multivariate analysis estimated the odds of screening, controlling for individual and county-level effects.Results: Rural residents, particularly those in persistent poverty counties, were less likely to be screened than urban residents. More African Americans in persistent poverty rural counties reported not having mammography screening (18.3%) compared to 15.9% of urban African Americans. Hispanics had low screening rates across all service types. Multivariate analysis continued to find disparities in screening rates, after controlling for individual and county-level factors. African Americans in persistent poverty rural counties were more likely to be screened for both breast cancer (odds ratio, 1.44; 95% confidence interval, 1.12-1.85) and cervical cancer (1.46; 1.07-1.99) when compared with urban whites. Conclusions: Disparities in cancer screening rates exist across not only race/ethnicity but also county type. These disparities cannot be fully explained by either individual or county-level effects. Programs have been successful in improving screening rates for African American women and should be expanded to target other vulnerable women as well as other services such as colorectal cancer screening.

Health disparities and health-seeking behavior among Latino men: a review of the literature

Many studies examining Latino health-seeking behavior have focused on comparing Latinos with other ethnic groups, primarily with Whites and African Americans. However, without the benefit of intragroup or intracultural comparisons, such studies fail to identify the subtle variation in health-seeking strategies and the range of needs within the Latino ethnic group, and thus are compromised in their capacity to guide and improve practice and policy. This article reviews the literature regarding health-seeking behavior and Latino men. Important factors identified include gender, occupation, and responsiveness of the health care system along with characteristics of the individual.

Access to health care for nonmetro and metro Latinos of Mexican origin in the United States

BACKGROUND

A growing number of Latinos are moving to nonmetro areas, but little research has examined how this trend might affect the Latino-disadvantage in access to healthcare.

OBJECTIVE

We investigate health care access disparities between non-Latino whites and Latinos of Mexican origin, and whether the disparities differ between metro and nonmetro areas.

METHODS

A series of logistic regression models provide insight on whether individuals have a usual source of care and whether they have had any physician visits in the past year. Our analyses focus on the interaction between Mexican origin descent and nonmetro residence.

SUBJECTS

Nationally representative data from the 2002-2003 Medical Expenditure Panel Survey are analyzed. The sample consists of working-aged adults age 18-64, yielding a sample size of 29,875.

RESULTS

The Mexican disadvantage in having a usual source of care is much greater among nonmetro residents than among those living in metro areas. The Mexican disadvantage in the likelihood of seeing a physician at least 1 time during the year does not differ across locations. Although general and ethnicity-specific predictors explain the disadvantage of Mexicans in having a usual source of care, they do not explain the added disadvantage of being Mexican and living in nonmetro areas.

CONCLUSIONS

This study identifies a new challenge to the goal of eliminating health care disparities in the United States. The Latino population living in nonmetro areas is growing, and our findings suggest that Latinos in nonmetro areas face barriers to having a usual source of care that are greater than those faced by Latinos in other areas.

Rural access to vocational rehabilitation services: minority farmers' perspective

PURPOSE

The paper documents the need for, and obstacles to effective access to rehabilitation services by minority farmers. It draws from the findings of a study conducted in the Mississippi delta.

METHOD

Applying community-based participatory research approach (CBPR) the study trained farmers to conduct interviews and focus group discussions. They interviewed 1308 farmers and had 18 focus group discussions with 254 farmers. The study also interviewed 290 service providers and conducted 8 focus group discussions with 72 State Vocational Rehabilitation services (VR) counselors.

RESULTS

The study found an unmet need for VR services in this population. Farmers were not aware of VR services or how to access them and VR was not aware of farmers' needs. Farmers felt marginalized and afraid that access to VR services would diminish their ability to earn a living on the farm.

CONCLUSIONS

Collaboration between VR and rural organizations, agencies and with rural people would help close the information and gaping service gap. One-stop service centers in rural areas could improve access to services. CBPR is an invaluable research tool especially among marginalized people.

Addressing substance abuse in health care settings

This article summarizes the proceedings of a roundtable discussion at the 2005 annual meeting of the Research Society on Alcoholism in Santa Barbara, California. The chair was William R. Miller. The presentations were as follows: (1) Screening and Brief Intervention for Alcohol Problems, by Allen Zweben; (2) Three Intervention Models and Their Impact on Medical Records, by Denise Ernst; (3) Pharmacotherapies for Managing Alcohol Dependence in Health Care Settings, by Roger D. Weiss; (4) The Trauma Center as an Opportunity, by Carol R. Schermer; (5) Motivational Interviewing by Telephone and Telemedicine, by Catherine Baca; (6) Health Care as a Context for Treating Drug Abuse and Dependence, by Wilson M. Compton; and (7) Interventions for Heavy Drinking in Health Care settings: Barriers and Strategies, by Mark L. Willenbring.

Organizational Technologies of Chronic Disease Management Programs in Large Rural Multispecialty Group Practice Systems

Four large rural multispecialty group practice systems employ a mix of organizational technologies to provide chronic disease management with measurable impacts on their patient populations and costs. Four technologies-administrative, clinical, information, and social-are proposed as key dimensions for examining disease management programs. The benefits of disease management are recognized by these systems despite marked variability in the organization of the programs. Committees spanning health plans and clinics in the 4 systems and electronic medical records and/or other disease management information systems are important coordinating mechanisms. Increased reliance on nurses for patient education and care coordination in all 4 systems reflects significant extension of clinical and social technologies in the management of patient care. The promise of disease management as offered by these systems and other auspices are considered.

Context and healthcare access: looking beyond the individual

BACKGROUND

Although health is influenced by an individual's characteristics and choices, accumulating evidence suggests that contextual attributes may influence a variety of health outcomes. Whether these factors also represent "upstream" factors affecting one's ability to enter the healthcare system is less clear, however.

OBJECTIVE

The objective of this study was to assess associations between contextual characteristics and an individual's report of having a usual source of health care.

RESEARCH DESIGN

Cross-sectional, survey-weighted data assessing demographics, insurance status, needs, and healthcare access were obtained through telephone survey in 1998 and were linked with county-level data from the 1998 Area Resource File and the 1990 US Census.

SUBJECTS

A state-representative sample of 16,261 adult residents, living in urban, suburban, and rural settings throughout Ohio comprised this study.

MEASURES

Operational measures for social, economic, and health system characteristics were used in multilevel logistic regression models to test associations with an individual's report of a usual source of care.

RESULTS

The weighted proportion of individuals reporting no usual source of care was 18.0%. Although individuals' current health, insurance status, income, demographics, educational attainment, and social support were closely associated with this outcome, significant associations remained for county-level characteristics representing the level of poverty and degree of urbanization.

CONCLUSIONS

Persisting health status disparities increase the need for programs that promote equitable access to health care. Policy interventions may be more effective if they look beyond individual characteristics to incorporate strategies that address economic factors in areas where healthcare access is inequitable.

EMPLOYMENT AND HEALTH INSURANCE COVERAGE FOR RURAL LATINO POPULATIONS

Rural Latino populations continue to grow in part due to relocation of food processing industries to rural America along with other manufacturing and large retail stores. We use data from the Current Population Survey to examine the labor force participation of rural Latino population and the role rural employers play in providing health insurance coverage. We found that while rural Latinos are more likely to be uninsured, the meat packing industry has higher health insurance coverage rates than other rural employers such as construction and retail. Local communities recruiting new businesses to their rural communities need to explore the role that employers will play in providing health insurance coverage. Lack of adequate coverage will have an impact on the income, resources, and day-to-day activities of physicians, hospitals and traditional safety net providers.

Providing health care to Latino immigrants: community-based efforts in the rural midwest

We examined case studies of 3 rural Midwestern communities to assess local health care systems' response to rapidly growing Latino populations. Currently, clinics provide free or low-cost care, and schools, public health, social services, and religious organizations connect Latinos to the health care system. However, many unmet health care needs result from lack of health insurance, limited income, and linguistic and cultural barriers. Targeted safety net funding would help meet Latino health care needs in rural communities with limited resources.

Person and place: the compounding effects of race/ethnicity and rurality on health

Rural racial/ethnic minorities constitute a forgotten population. The limited research addressing rural Black, Hispanic, and American Indian/Alaska Native populations suggests that disparities in health and in health care access found among rural racial/ethnic minority populations are generally more severe than those among urban racial/ethnic minorities. We suggest that disparities must be understood as both collective and contextual phenomena. Rural racial/ethnic minority disparities in part stem from the aggregation of disadvantaged individuals in rural areas. Disparities also emerge from a context of limited educational and economic opportunity. Linking public health planning to the education and economic development sectors will reduce racial/ethnic minority disparities while increasing overall well-being in rural communities.

Disparities in access to care among rural working-age adults

CONTEXT

Nationally, minority population disparities in health and in the receipt of health services are well documented but are infrequently examined within rural populations.

PURPOSE

The purpose of this study is to provide a national picture of health insurance coverage and access to care among rural minorities.

METHODS

A cross-sectional analysis using the 1999-2000 National Health Interview Surveys examined insurance status and receipt of ambulatory care during the past year. Multiple logistic regression was used to measure factors influencing the odds of insurance coverage and a provider visit.

FINDINGS

Among rural minority adults, 32% of blacks, 35% of "other" race persons, and 45% of Hispanics were uninsured compared to 18% of whites. Differences in insurance status were not significant for rural blacks and Hispanics after resources such as education, income, and employment were held constant. Examining use, 37% of rural Hispanics and 27% of blacks, versus 20% of whites and 19% of persons of other race, had not made a health care visit in the past year. When resources were held constant, blacks and persons of other race/ethnicity no longer differed from whites, but differences among Hispanics persisted.

CONCLUSIONS

A comprehensive approach to the health needs of rural working age adults must consider the unique characteristics of rural communities and populations, requiring cultural as well as financial creativity in the design of health delivery systems. The importance of resources such as education and employment points to the need to link health problems to area-specific rural economic development.

Improving Access to Primary Care for a Growing Latino Population: The Role of Safety Net Providers in the Rural Midwest

CONTEXT

Many rural Midwestern communities are experiencing rapid growth in Latino populations with low rates of health insurance coverage, limited financial resources, language and cultural differences, and special health care needs.

PURPOSE

We report on 2-day site visits conducted in 2001 and 2002 in 3 communities (Marshalltown, Iowa; Great Bend, Kansas; and Norfolk, Nebraska) to document successful strategies to meet Latino health care needs.

METHODS

We interviewed key informants to identify successful community strategies for dealing with health care access challenges facing the growing Latino population in the Midwest.

FINDINGS

Interventions have been developed to meet new demands including (1) use of free clinics, (2) school health programs, (3) outreach by public health, social services and religious organizations, and (4) health care providers' efforts to communicate with patients in Spanish. Strain on safety net services for Latinos is due in part to a complicated and unstable mix of public and private funds, a large but overtaxed volunteer provider base, the dependence on a limited number of community leaders, and limited time for coordination and documentation of activities.

CONCLUSIONS

We suggest the development of a Rural Safety Net Support System to provide targeted funding to rural areas with growing immigrant populations. Federal community health center support could be redirected to new and existing safety net providers to support the development of a safety net monitoring system.

Costs and strategies in minority recruitment for osteoporosis research

To meet expectations for the participation of minority populations in research, we committed to enroll 140 minority subjects in addition to a random sample of Olmsted County, Minnesota residents (90% white) for a study of risk factors for age-related bone loss and fractures. We successfully enrolled 597 additional minority subjects but encountered specific problems with respect to identification of potential subjects, recruitment, obtaining informed consent, transportation to the study site, and collecting study data. These problems were resolved by observing the tenets of outreach to a diverse study population, namely (1) understand the target population; (2) establish explicit recruitment goals; (3) agree on research plans between study staff and minority communities; (4) continuously evaluate the recruitment process; and (5) maintain lines of communication. Success depended especially on the recruitment of cultural advisors from the different ethnic groups. These special efforts increased the recruitment cost substantially; the total expense of $122,000 for recruiting 550 Asian, Hispanic, and Somali subjects was almost 5-fold higher than the $26,000 required to recruit 699 mostly white study subjects from the population who were contacted by mail. Although it is not impossible to recruit minority subjects, investigators (and grant reviewers) should recognize that significant resources are required to gain access to ethnic communities for research. These results should contribute to more realistic budgets for recruiting minority subjects into clinical research studies.

An outreach intervention for older rural African Americans

This article describes the process, approaches, and selected outcomes of a rural care management outreach intervention for older African Americans in South Carolina. The model is a community-academic partnership between a federally qualified community health center, a rural health clinic, and the Medical University of South Carolina. Its aim is to improve access to and utilization of health care and social services to enhance the quality of life of older African Americans. This is being accomplished by using paid, trained outreach workers (called geriatric coordinators), who function as advocates in linking clients to needed health and social services through activities such as arranging transportation to health care, rescheduling missed medical appointments, providing health promotion, and making referrals to public benefits and indigent drug programs. Outcomes demonstrated that the use of geriatric coordinators as care managers is a feasible way of increasing quality of life for older African Americans. The most notable outcome showed that 54% of clients who were eligible but not receiving benefits prior to this intervention were signed on for programs such as Supplemental Security Income, Specified Low-Income Medicare Beneficiary (SLMB), Qualified Medicare Beneficiary (QMB), disability, railroad pensions, and Veterans Administration benefits. Health centers realized an increase in reimbursable services and new clients. Increased capacity for older adult services is being accomplished through geriatric-coordinator-directed collaborations with social service agencies and participation in community events and committees.

The impact of asthma risk factors on home management of childhood asthma

There have been few studies of childhood asthma among families who live in nonmetropolitan settings. This work is part of the baseline assessment conducted before implementing a health education program to study the impact of asthma risk factors (gender, ethnicity, socioeconomic status, asthma severity) on home asthma management. Data analysis yielded no significant differences in home asthma management performed by parents or children with asthma based on the child's gender, ethnicity, asthma severity, or family socioeconomic status. Factors that define the child's experienced asthma pattern, such as activity limitations, number of allergens, and school absenteeism, were associated with the parent's work of asthma management. Trends in the data for the different ethnic and gender subgroups that have implications for clinical practice were identified. Future directions for research to address questions that emerged in this analysis are discussed.

Race and ethnicity as variables in Nursing Research, 1952-2000

BACKGROUND

Although the use of race and ethnicity as variables in research has increased over the past five decades, there is confusion regarding the meaning of the terms, as well as how the words are defined and determined in scientific inquiry.

OBJECTIVE

To review the use of race and ethnicity as variables in nursing research literature.

METHODS

Original research articles published in Nursing Research in the years, 1952, 1955, and every 5 years thereafter through 2000 were reviewed. Those articles describing human characteristics (N = 337) were analyzed for content concerning: (a) frequency of racial and ethnic terms, (b) words used for racial and ethnic categories, (c) detinitions of racial and ethnic terms, and (d) how a study participant's race or ethnicity was determined.

RESULTS

Racial and ethnic variables were mentioned in 167 of the 337 reviewed articles. Eighty-one terms and word phrases were used for these variables. In only five articles were the variables defined. Race and ethnic labels were often intermixed and the majority of studies provided no information about how categorization of the participant's race or ethnicity was made. In addition, there was relatively little growth in the number of studies that had racial/ethnic groups, other than Whites, as the majority of the sample.

CONCLUSION

Racial and ethnic variables provide nurse researchers with many challenges. Although race and ethnicity were widely used in Nursing Research articles, the categories were not defined in the majority of papers, and methods used to determine a participant's race or ethnicity were unclear. In order to construct a common and consistent understanding of racial and ethnic categories, nurse researchers should be explicit regarding the rationale related to their use of the categories and the assumptions underlying particular racial and ethnic categorizations.

Access to care for rural Medicare beneficiaries

This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self-reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems; instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self-reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self-reported access, satisfaction and utilization than does rural residence per se.