Nutrition Environment Gaps and Distribution Challenges in Rural Food Pantries During the COVID-19 Pandemic: A Mixed-Methods Study

BACKGROUND

Food insecurity disproportionately affects low-income, racially marginalized, and rural communities. The COVID-19 pandemic led to higher demand for emergency food distribution, potentially impacting food pantry operations and services. Limited research exists assessing consumer nutrition environments of pantries in rural regions.

OBJECTIVES

To assess the consumer nutrition environment of rural food pantries and report challenges and adaptations encountered during the pandemic.

DESIGN

A mixed-methods, cross-sectional survey.

PARTICIPANTS/SETTING

Nineteen food pantry representatives from California's San Joaquin Valley were surveyed between August 2020 and June 2021. Representatives were eligible if their pantry served the general population and was open at least once a week. Nine were church-based pantries, and 10 were from other settings.

MAIN OUTCOME MEASURES

The Nutrition Environment Food Pantry Assessment Tool (NEFPAT) measured the nutrition food environment and scored pantries as bronze (0-15), silver (16-31), or gold (32-47) categories. Eleven items were developed to explore pandemic-related challenges.

STATISTICAL ANALYSES PERFORMED

Independent χ2 tests assessed the relationship between the organization type and NEFPAT scores and food supply sources. Fisher's exact test explored associations between food pantry type, NEFPAT category, and challenges. Nonparametric tests were run on non-normally distributed data. Inductive content analysis was used to examine open-ended pandemic-related questions.

RESULTS

The nutrition environment of most pantries was suboptimal, because no pantry scored in the "gold" category based on total NEFPAT scores (median, 18 of 47). No statistically significant differences were found in the NEFPAT scores by organization type. Most pantries did not provide healthy food nudges or culturally diverse foods. Key COVID-19 challenges encountered consisted of supply- and demand-side issues, including reduced personnel, capacity, and resources, and increased client quantity and demand for food.

CONCLUSIONS

Assessing the nutrition environment of rural food pantries revealed gaps and strategies for improvement, including the use of healthy nudges and increasing the availability of culturally diverse foods.

Pediatric Gender Care in Primary Care Settings in West Virginia: Provider Knowledge, Attitudes, and Educational Experiences

PURPOSE

Pediatric primary care providers (PPCPs) often care for gender diverse youth (GDY), particularly in rural areas, but little is known about their relevant knowledge, attitudes, or educational experiences regarding caring for this population.

METHODS

This study surveyed PPCPs throughout the rural state of West Virginia using an online survey assessing 1) demographics, 2) knowledge, 3) attitudes, and 4) educational experiences. Knowledge and attitude scores were calculated and proportion-tests and t-tests were used to compare these scores by PPCP characteristics including age, time in practice, and training background.

RESULTS

In total, 51 PPCPs from throughout the state completed the survey and 82% had cared for GDY in the prior year. Younger providers (

DISCUSSION

PPCPs in a rural state reported caring for GDY, but knowledge and attitudes related to this care varied by age, time in practice, and relevant educational experiences. More research is needed to determine best strategies for providing education to PPCPs, particularly those who are older and have been in practice longer, and to better understand the impacts of legislation limiting evidence-based gender-affirming care on PPCP knowledge, attitudes, and access to educational experiences.

Collapse

Key Words

• LGBTQ
• Pediatrics
• Primary care
• Rural health

Collapse

MESH Headings

• Humans
• West Virginia
• Female
• Male
• Health Knowledge, Attitudes, Practice
• Adult
• Primary Health Care
• Surveys and Questionnaires
• Attitude of Health Personnel
• Middle Aged
• Pediatrics/education
• Adolescent

Collapse

Grants

• U54 GM104942 NIGMS NIH HHS

Collapse

Affiliation(s)

Kacie M Kidd Division of Adolescent Medicine, Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia.
Alana Slekar West Virginia University, Morgantown, West Virginia
Gina M Sequeira Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
Nicole F Kahn Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
Lisa M Costello Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
Isabela Negrin Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
Sara Farjo WVU Urgent Care, West Virginia University School of Medicine, Morgantown, West Virginia
Savannah Lusk Department of Family Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
Snehalata Huzurbazar Department of Mathematics and Data Science, West Virginia University, Morgantown, West Virginia
Janani Narumanchi Department of Pediatrics, University of Tennessee School of Medicine, Memphis, Tennessee

Collapse

Colonoscopy Outreach for Rural Communities (CORC): A study protocol of a pragmatic randomized controlled trial of a patient navigation program to improve colonoscopy completion for colorectal cancer screening

BACKGROUND

Colonoscopy is one of the primary methods of screening for colorectal cancer (CRC), a leading cause of cancer mortality in the United States. However, up to half of patients referred to colonoscopy fail to complete the procedure, and rates of adherence are lower in rural areas.

OBJECTIVES

Colonoscopy Outreach for Rural Communities (CORC) is a randomized controlled trial to test the effectiveness of a centralized patient navigation program provided remotely by a community-based organization to six geographically distant primary care organizations serving rural patients, to improve colonoscopy completion for CRC.

METHODS

CORC is a type 1 hybrid implementation-effectiveness trial. Participants aged 45-76 from six primary care organizations serving rural populations in the northwestern United States are randomized 1:1 to patient navigation or standard of care control. The patient navigation is delivered remotely by a trained lay-person from a community-based organization. The primary effectiveness outcome is completion of colonoscopy within one year of referral to colonoscopy. Secondary outcomes are colonoscopy completion within 6 and 9 months, time to completion, adequacy of patient bowel preparation, and achievement of cecal intubation. Analyses will be stratified by primary care organization.

DISCUSSION

Trial results will add to our understanding about the effectiveness of patient navigation programs to improve colonoscopy for CRC in rural communities. The protocol includes pragmatic adaptations to meet the needs of rural communities and findings may inform approaches for future studies and programs.

TRIAL REGISTRATION

National Clinical Trial Identifier: NCT05453630.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT05453630. Registered July 6, 2022.

Drinking water sources, quality, and associated health outcomes in Appalachian Virginia: A risk characterization study in two counties

OBJECTIVES

In the US, violations of drinking water regulations are highest in lower-income rural areas overall, and particularly in Central Appalachia. However, data on drinking water use, quality, and associated health outcomes in rural Appalachia are limited. We sought to assess public and private drinking water sources and associated risk factors for waterborne pathogen exposures for individuals living in rural regions of Appalachian Virginia.

METHODS

We administered surveys and collected tap water, bottled water, and saliva samples in lower-income households in two adjacent rural counties in southwest Virginia (bordering Kentucky and Tennessee). Water samples were tested for pH, temperature, conductivity, total coliforms, E. coli, free chlorine, nitrate, fluoride, heavy metals, and specific pathogen targets. Saliva samples were analyzed for antibody responses to potentially waterborne infections. We also shared water analysis results with households.

RESULTS

We enrolled 33 households (83 individuals), 82% (n = 27) with utility-supplied water and 18% with private wells (n = 3) or springs (n = 3). 58% (n = 19) reported household incomes of <$20,000/year. Total coliforms were detected in water samples from 33% (n = 11) of homes, E. coli in 12%, all with wells or springs (n = 4), and Aeromonas, Campylobacter, and Enterobacter in 9%, all spring water (n = 3). Diarrhea was reported for 10% of individuals (n = 8), but was not associated with E. coli detection. 34% (n = 15) of saliva samples had detectable antibody responses for Cryptosporidium spp., C. jejuni, and Hepatitis E. After controlling for covariates and clustering, individuals in households with septic systems and straight pipes had significantly higher likelihoods of antibody detection (risk ratios = 3.28, 95%CI = 1.01-10.65).

CONCLUSIONS

To our knowledge, this is the first study to collect and analyze drinking water samples, saliva samples, and reported health outcome data from low-income households in Central Appalachia. Our findings indicate that utility-supplied water in this region was generally safe, and individuals in low-income households without utility-supplied water or sewerage have higher exposures to waterborne pathogens.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

INTRODUCTION

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

METHODS

We conducted 40 semi-structured interviews in the United States from May 2020-Feburary 2022 with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) Model. The audiences were recruited by multiple methods including fliers, a community advisory board, Facebook ads, phone calls or emails to schools and health systems, and snowball sampling. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities. We used deductive coding approach using a structured codebook, two coders, analyses in MAXQDA, and matrices.

RESULTS

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level) and community outreach, providers' approach to the HPV vaccine recommendations and use of educational materials in addition to counseling parents or young adults (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and health education information around HPV vaccination (practice level). Related to socio-ecology, the lack of transportation and culture of limited discussion about vaccination in rural communities and the lack of policies facilitating the uptake of the HPV vaccine (e.g., school mandates) were described as challenges.

CONCLUSION

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

Addressing food insecurity in rural primary care: a mixed-methods evaluation of barriers and facilitators

BACKGROUND

Food insecurity (FI) is associated with negative health outcomes and increased healthcare utilization. Rural populations face increased rates of FI and encounter additional barriers to achieving food security. We sought to identify barriers and facilitators to screening and interventions for FI in rural primary care practices.

METHODS

We conducted a mixed-methods study using surveys and semi-structured interviews of providers and staff members from rural primary care practices in northern New England. Survey data were analyzed descriptively, and thematic analysis was used to identify salient interview themes.

RESULTS

Participants from 24 rural practices completed the survey, and 13 subsequently completed an interview. Most survey respondents (54%) reported their practices systematically screen for FI and 71% reported food needs were "very important" for their patients and communities. Time and resource constraints were the most frequently cited barriers to screening for and addressing FI in practices based on survey results. Interview themes were categorized by screening and intervention procedures, community factors, patient factors, external factors, practice factors, process and implementation factors, and impact of FI screening and interventions. Time and resource constraints were a major theme in interviews, and factors attributed to rural practice settings included geographically large service areas, stigma from loss of privacy in small communities, and availability of food resources through farming.

CONCLUSIONS

Rural primary care practices placed a high value on addressing food needs but faced a variety of barriers to implementing and sustaining FI screening and interventions. Strategies that utilize practice strengths and address time and resource constraints, stigma, and large service areas could promote the adoption of novel interventions to address FI.

Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services

INTRODUCTION

Hospitals are an ideal setting to stage opioid-related interventions with patients who are hospitalized due to overdose or other substance use-related complications. Transitional opioid programs-which initiate care and provide linkages upon discharge, such as screening, initiation of medications for opioid use disorder, and addiction consult services-have become the gold standard, but implementation has been uneven. The purpose of this study was to assess disparities in the availability of hospital-based transitional opioid programs, across rural and urban hospital settings in the United States.

METHODS

Using hospital administrative data paired with county-level demographic data, we conducted bivariate and regression analyses to assess rural-urban differences in the availability of transitional opioid services including screening, addiction consult services, and MOUD in U.S general medical centers, controlling for hospital- and community-level factors. Our sample included 2846 general medical hospitals that completed the 2021 American Hospital Association (AHA) Annual Survey of Hospitals. Our primary outcomes were five self-reported measures: whether the hospital provided screening in the ED; provided screening in the inpatient setting; whether the hospital provided addiction consult services in the ED; provided addiction consult services in the inpatient setting; and whether the hospital provided medications for opioid use disorder.

RESULTS

Rural hospitals did not have lower odds of screening for OUD or other SUDs than urban hospitals, but both micropolitan rural counties and noncore rural counties had significantly lower odds of having addiction consult services in either the ED (OR: 0.74, 95 % CI: 0.58, 0.95; OR: 0.68, 95 % CI: 0.50, 0.91) or inpatient setting (OR: 0.76, 95 % CI: 0.59, 0.97; OR: 0.68, 95 % CI: 0.50, 0.93), respectively, or of offering MOUD (OR: 0.69, 95 % CI: 0.52, 0.90; OR: 0.52, 95 % CI: 0.37, 0.74).

CONCLUSIONS

Our study suggests that evidence-based interventions, such as medications for opioid use disorder and addiction consult services, are less often available in rural hospitals, which may contribute to rural-urban disparities in health outcomes secondary to OUD. A priority for population health improvement should be developing implementation strategies to support rural hospital adoption of transitional opioid programs.

Predictors of opioid use for rib fractures in a regional Australian hospital

BACKGROUND

Rib fractures (RFs) are the leading type of single serious injury in New South Wales trauma patients. Uncontrolled pain drives the sequelae of atelectasis, pneumonia, respiratory failure, and death in severe cases. Opioids are the mainstay of management; however, they carry numerous adverse effects. Understanding patient or injury factors which predict opioid requirement is important to tailor management. Existing evidence is limited to metropolitan trauma centres (MTCs).

METHODS

We conducted an observational, retrospective, single-centre cohort study of all admissions to Albury Wodonga Health diagnosed with one or more RFs and discharged between January 1st, 2017, and December 31st, 2022, inclusive. Data collected included demographics, injury characteristics, and management, including analgesia. LASSO regression was performed to determine predictors of average daily opioid use for the first five days of admission in oral morphine equivalents (mg). R2 and root mean square error (RMSE) were calculated to assess model performance.

RESULTS

We included 624 patients. LASSO selected number of RFs, fracture displacement score, pulmonary contusion, new injury severity score, age, chest tube use, chronic pain history, opioid history and upper or middle lateral RF location categories as predictors. Sex, middle anterior, middle posterior, and lower RF location categories were excluded by LASSO. The out of sample R2 was 28.6 %. On the scale of log OME, the RMSE was 1.08.

CONCLUSION

The model is effective at identifying predictors of opioid use in this regional centre, which are similar to those described in evidence from MTCs. However, the low R2 with wide prediction intervals limits its utility on an individual level.

Comparative analysis of village doctors' relative deprivation: based on two cross-sectional surveys

BACKGROUND

Village doctors are the main health service providers in China's rural areas. Compared with other rural groups, they will have a sense of relative deprivation, which has an impact on their practice mentality and job stability. This study aims to analyze the changes and causes of relative deprivation among village doctors, so as to improve the stability of them.

METHODS

The data were collected from two surveys conducted in Shandong Province in 2015 and 2021. In 2015, 322 village doctors were surveyed and 307 questionnaires were collected, with a recovery rate of 95.3%. In 2021, 394 village doctors were surveyed and 366 questionnaires were collected, with a recovery rate of 92.9%. Descriptive and univariate analysis were used to compare the changes before and after the survey.

RESULTS

The scores of vertical deprivation of village doctors increased from 2.77 ± 0.81 in 2015 to 3.04 ± 0.83 in 2021, with a statistically significant difference (P < 0.001). The reference group selected by village doctors changed from village teachers to ordinary villagers. Compared to village teachers, the horizontal deprivation score of village doctors increased from 3.47 ± 0.87 to 3.97 ± 0.77, with a statistically significant difference (P < 0.001). Compared to villagers, only the professional reputation deprivation score increased, from 2.38 ± 0.93 to 2.68 ± 0.76, with a statistically significant difference (P < 0.05).

CONCLUSIONS

As time goes by, village doctors fail to reach the expected level in terms of economic income, social status, professional reputation and living standards, resulting in a sense of relative deprivation. This may have a negative impact on village doctors' work motivation and behavior, and will fail to guarantee the sustainability of the team. We should pay attention to this unbalanced mentality of village doctors.

Patient experiences in primary care do not differ according to rurality: a cross-sectional study

BACKGROUND

Living in rural areas is a major contributor of health inequity. Tackling health inequity is important for primary care physicians. Therefore, it is important to compare the quality of primary care between rural and urban areas. To the best of our knowledge, this is the first study to examine the association between rurality and patient experience (PX) in Japan using validated measures.

METHODS

This cross-sectional study was conducted using online surveys. Participants were selected using a stratified random sample based on sex and age. The Japanese version of the Person-Centered Primary Care Measure (PCPCM) was used as an indicator of PX. We used the Rurality Index for Japan (RIJ) to measure rurality. Furthermore, we used multivariate linear regression analysis to examine the relationship between the RIJ and PCPCM after adjusting for confounders.

RESULTS

Of the 1112 eligible participants, 800 responded to the survey (response rate:71.9%). The mean PCPCM scores were 2.46 (standard deviation: 0.73) and median RIJ was 15 (interquartile range: 6-33). The crude and adjusted coefficients of rurality were - 0.02 (- 0.006-0.001, p = 0.114) and - 0.02 (- 0.005-0.001), respectively, demonstrating that rurality was not significantly associated with the total PCPCM score. Subgroup analyses were similar to the main analyses.

CONCLUSION

We found that PX in primary care did not differ by rurality in the general Japanese population.

Evaluation of respondent-driven sampling in seven studies of people who use drugs from rural populations: findings from the Rural Opioid Initiative

BACKGROUND

Accurate prevalence estimates of drug use and its harms are important to characterize burden and develop interventions to reduce negative health outcomes and disparities. Lack of a sampling frame for marginalized/stigmatized populations, including persons who use drugs (PWUD) in rural settings, makes this challenging. Respondent-driven sampling (RDS) is frequently used to recruit PWUD. However, the validity of RDS-generated population-level prevalence estimates relies on assumptions that should be evaluated.

METHODS

RDS was used to recruit PWUD across seven Rural Opioid Initiative studies between 2018-2020. To evaluate RDS assumptions, we computed recruitment homophily and design effects, generated convergence and bottleneck plots, and tested for recruitment and degree differences. We compared sample proportions with three RDS-adjusted estimators (two variations of RDS-I and RDS-II) for five variables of interest (past 30-day use of heroin, fentanyl, and methamphetamine; past 6-month homelessness; and being positive for hepatitis C virus (HCV) antibody) using linear regression with robust confidence intervals. We compared regression estimates for the associations between HCV positive antibody status and (a) heroin use, (b) fentanyl use, and (c) age using RDS-1 and RDS-II probability weights and no weights using logistic and modified Poisson regression and random-effects meta-analyses.

RESULTS

Among 2,842 PWUD, median age was 34 years and 43% were female. Most participants (54%) reported opioids as their drug of choice, however regional differences were present (e.g., methamphetamine range: 4-52%). Many recruitment chains were not long enough to achieve sample equilibrium. Recruitment homophily was present for some variables. Differences with respect to recruitment and degree varied across studies. Prevalence estimates varied only slightly with different RDS weighting approaches, most confidence intervals overlapped. Variations in measures of association varied little based on weighting approach.

CONCLUSIONS

RDS was a useful recruitment tool for PWUD in rural settings. However, several violations of key RDS assumptions were observed which slightly impacts estimation of proportion although not associations.

Epidemiological approaches to multivariable models of health inequity: A study of race, rurality, and occupation during the COVID-19 pandemic

PURPOSE

Methods for assessing the structural mechanisms of health inequity are not well established. This study applies a phased approach to modeling racial, occupational, and rural disparities on the county level.

METHODS

Rural counties with disparately high rates of COVID-19 incidence or mortality were randomly paired with in-state control counties with the same rural-urban continuum code. Analysis was restricted to the first six months of the pandemic to represent the baseline structural reserves for each county and reduce biases related to the disruption of these reserves over time. Conditional logistic regression was applied in two phases-first, to examine the demographic distribution of disparities and then, to examine the relationships between these disparities and county-level social and structural reserves.

RESULTS

In over 200 rural county pairs (205 for incidence, 209 for mortality), disparities were associated with structural variables representing economic factors, healthcare infrastructure, and local industry. Modeling results were sensitive to assumptions about the relationships between race and other social and structural variables measured at the county level, particularly in models intended to reflect effect modification or mediation.

CONCLUSIONS

Multivariable modeling of health disparities should reflect the social and structural mechanisms of inequity and anticipate interventions that can advance equity.

Distance to endoscopy services amplifies racial inequities in colorectal cancer mortality in Washington state

BACKGROUND

This study evaluates relationships among race, access to endoscopy services, and colorectal cancer (CRC) mortality in Washington state (WA).

METHODS

We overlayed the locations of ambulatory endoscopy services with place of residence at time of death, using Department of Health data (2011-2018). We compared CRC mortality data within and outside a 10 ​km buffer from services. We used linear regression to assess the impact of distance and race on age at death while adjusting for gender and education level.

RESULTS

Age at death: median 72.9y vs. 68.2y for white vs. non-white (p ​< ​0.001). The adjusted model showed that non-whites residing outside the buffer died 6.9y younger on average (p ​< ​0.001). Non-whites residing inside the buffer died 5.2y younger on average (p ​< ​0.001), and whites residing outside the buffer died 1.6y younger (p ​< ​0.001). We used heatmaps to geolocate death density.

CONCLUSIONS

Results suggest that geographic access to endoscopy services disproportionately impacts non-whites in Washington. These data help identify communities which may benefit from improved access to alternative colorectal cancer screening methods.

Changes in food sufficiency among Korean adults in urban and rural areas during the COVID-19 pandemic: an analysis of the 7th and 8th Korea National Health and Nutrition Examination Survey

Objectives

Understanding changes in food sufficiency within various demographic groups during emergency situations, such as the global coronavirus disease 2019 (COVID-19) pandemic, is crucial in formulating public health policies for future preparedness. This study investigated potential differences between urban and rural residents in food sufficiency trends during the COVID-19 pandemic and examined how these changes varied according to sociodemographic factors.

Methods

This cross-sectional study analyzed data from 19,724 adults aged 20 years and older, utilizing information from the 7th-8th Korea National Health and Nutrition Examination Survey (2018-2021).

Results

In urban areas, across all subpopulations, food sufficiency improved significantly during the COVID-19 period relative to pre-pandemic levels (p<0.001). However, in rural regions, a significant increase in food sufficiency during the COVID-19 era was observed only among women, with an odds ratio of 1.42 (confidence interval, 1.06 to 1.89). Nevertheless, no significant interaction terms were found between region and various sociodemographic factors regarding changes in food sufficiency during the COVID-19 period.

Conclusion

During the COVID-19 pandemic, food sufficiency among urban residents improved compared to the pre-pandemic era, whereas their rural counterparts saw no such improvement. Additionally, no significant interaction was detected between urban versus rural areas and changes in food sufficiency during the COVID-19 period. These findings indicate the need for targeted food policies to prepare for potential future pandemics, particularly in rural areas, where food sufficiency did not improve.

The impact of incentive scheme on rural healthcare workforce availability: a case study of Kazakhstan

BACKGROUND

During the 1990-2000, Kazakhstan experienced a decline in the number of healthcare professionals working in rural areas. Since 2009, the national government has been implementing financial incentives to encourage healthcare professionals to relocate to rural areas. This study aims to investigate the temporal and spatial patterns in the distribution of the rural healthcare workforce and evaluate the impact of this incentive scheme.

METHODS

Interrupted Time Series Analysis using ARIMA models and Difference in Differences analyzes were conducted to examine the impact of the incentive scheme on the density of different categories of the healthcare workforce in rural Kazakhstan in the period from 2009 to 2020.

RESULTS

There was a significant increase in the number of rural healthcare professionals from 2009 to 2020 in comparison to the period from 1998 to 2008. However, this increase was less pronounced in per capita terms. Moreover, a decline in the density of internists and pediatricians was observed. There is substantial variation in the density of rural nurses and physicians across different regions of Kazakhstan. The incentive scheme introduced in 2009 by the government of Kazakhstan included a one-time allowance and housing incentive. This scheme was found to have contributed insignificantly to the observed increase in the number of rural healthcare professionals.

CONCLUSION

Future research should be undertaken to examine the impact made by the incentive scheme on other medical subspecialties, particularly primary practitioners. Addressing the shortage of healthcare workers in rural areas is a complex issue that requires a multifaceted approach. Aside from financial incentives, other policies could be considered to increase relocation and improve the retention of healthcare professionals in rural areas.

The relationship between felt stigma and non-fatal overdose among rural people who use drugs

BACKGROUND

Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs.

METHODS

Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose.

RESULTS

6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14).

CONCLUSIONS

Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

Getting patients to the right level of trauma center after motorcycle crashes in a rural trauma system

PURPOSE

After a motorcycle crash (MCC), emergency medical services (EMS) responders must balance trauma center proximity with clinical needs of patients, which is especially challenging in rural states. The study purpose was to determine if MCC patients treated at lower-level trauma centers (LLTC) experienced higher mortality when compared to patients transported directly to the highest level of trauma care available in the state at Level II trauma centers.

PROCEDURES

A retrospective study was conducted on MCC patients transported by EMS to Montana hospitals and met registry inclusion criteria in 2020-2021. The first study group included patients initially transported to state-designated trauma centers (equivalent to Level III-V) or non-designated hospitals (LLTC), and the second group included patients transported directly to American College of Surgeon verified Level II trauma centers (L2TC). Secondary transfer was defined as initial transport to a LLTC and subsequent transfer to a L2TC. Primary study outcome was mortality at the L2TC. Chi-square tests and Wilcoxon rank sum tests were used for analysis.

FINDINGS

In the study period, 337 MCC patients were transported by EMS; 186 (55%) patients were transported to a LLTC while 151 patients (45%) were transported to a L2TC. There were no statistically significant differences in mortality (12% vs 8%, p = 0.30) when comparing secondary transfer patients to patients transported directly to a L2TC.

CONCLUSIONS

Nearly half of patients initially evaluated at a LLTC required transfer to a higher-level of care. Secondary transfer was not associated with increased mortality.

Addressing the Spectrum of Opioid Misuse Prevention, Treatment, and Recovery in Rural Washington State Communities: Provider Identified Barriers and Needs

The opioid overdose epidemic has significantly impacted rural communities. Rural settings present unique challenges to addressing opioid misuse. The purpose of the current study was to understand the similarities and differences between rural and urban-based providers serving rural communities. Washington state-based opioid-related service providers who serve rural communities (N = 75) completed an online survey between July and September 2020. Chi-square tests of association were used to examine significant differences in proportions between rural providers and rural-serving urban providers across opioid prevention, treatment, and recovery training topics. Rural providers reported receiving significantly less opioid treatment and recovery training on the criminal legal system, workplace-based education on treatment and recovery, and co-occurring disorder treatment; and significantly higher prior opioid prevention training on the prevention programs for youth and accessing prevention funding. Differences between rural and rural-serving urban providers demonstrate ways in which rural-urban partnerships can be strengthened to enhance public health.

Rural-urban differences in use of health services before and after dementia diagnosis: a retrospective cohort study

BACKGROUND

Rural-urban differences in health service use among persons with prevalent dementia are known. However, the extent of geographic differences in health service use over a long observation period, and prior to diagnosis, have not been sufficiently examined. The purpose of this study was to examine yearly rural-urban differences in the proportion of patients using health services, and the mean number of services, in the 5-year period before and 5-year period after a first diagnosis of dementia.

METHODS

This population-based retrospective cohort study used linked administrative health data from the Canadian province of Saskatchewan to investigate the use of five health services [family physician (FP), specialist physician, hospital admission, all-type prescription drug dispensations, and short-term institutional care admission] each year from April 2008 to March 2019. Persons with dementia included 2,024 adults aged 65 years and older diagnosed from 1 April 2013 to 31 March 2014 (617 rural; 1,407 urban). Matching was performed 1:1 to persons without dementia on age group, sex, rural versus urban residence, geographic region, and comorbidity. Differences between rural and urban persons within the dementia and control cohorts were separately identified using the Z-score test for proportions (p < 0.05) and independent samples t-test for means (p < 0.05).

RESULTS

Rural compared to urban persons with dementia had a lower average number of FP visits during 1-year and 2-year preindex and between 2-year and 4-year postindex (p < 0.05), a lower likelihood of at least one specialist visit and a lower average number of specialist visits during each year (p < 0.05), and a lower average number of all-type prescription drug dispensations for most of the 10-year study period (p < 0.05). Rural-urban differences were not observed in admission to hospital or short-term institutional care (p > 0.05 each year).

CONCLUSIONS

This study identified important geographic differences in physician services and all-type prescription drugs before and after dementia diagnosis. Health system planners and educators must determine how to use existing resources and technological advances to support care for rural persons living with dementia.

The digital divide in rural and regional communities: a survey on the use of digital health technology and implications for supporting technology use

OBJECTIVE

A digital divide exists for people from rural and regional areas where they are less likely and confident to engage in digital health technologies. The aim of this study was to evaluate the digital health literacy and engagement of people from rural and regional communities, with a focus on identifying barriers and facilitators to using technology.

RESULTS

Forty adults living in rural/regional areas completed a survey consisting of the eHealth Literacy Scale (eHEALS) with additional items surveying participants' experience with a range of digital health technologies. All participants had used at least one digital health technology. Most (80%) participants had an eHEALS score of 26 or above indicating confidence in online health information. Commonly reported barriers to digital health technology use centred on product complexity and reliability, awareness of resources, lack of trust, and cost. Effective digital health technology use is becoming increasingly important, there may be a need to prioritise and support people with lower levels of digital health literacy. We present opportunities to support community members in using and accessing digital health technology.

Trends in Telerehabilitation Utilization in the United States 2020-2021

OBJECTIVE

To examine telerehabilitation utilization in the United States (US) during the first 2 years of the pandemic.

DESIGN

We performed a retrospective analysis of outpatient insurance claims from the IBM MarketScan Commercial Claims and Encounters Database to identify the number and proportion of patients using telerehabilitation from 2020 to 2021. Telerehabilitation was identified based on the presence of specific code modifiers and place of service.

SETTING

Retrospective claims analysis.

PARTICIPANTS

Individuals living in the United States with employer-sponsored insurance plans using outpatient physical or occupational therapy (PT/OT) (N=2,007,524).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Number and proportion of outpatient PT/OT visits completed via telerehabilitation.

RESULTS

We identified 21,026,608 PT/OT visits among 2,007,524 patients. Overall, 49,974 (2.5%) patients received ≥1 telerehabilitation visit during the specified timeframe. We observed trends in utilization over time, with utilization peaking in April 2020 when 10.9% of all PT/OT visits were conducted by telerehabilitation. We also observed geographic trends with lower rates of utilization identified in rural areas. State-by-state utilization rates ranged from 10.4% (California) to 0.3% (Wyoming).

CONCLUSION

Telerehabilitation may be underutilized as a means of improving access to PT/OT, especially in rural areas of the country. Further research is needed to examine contributing factors to low observed utilization rates, such as provider and patient perceptions of telerehabilitation.

Social Isolation and Safety Issues among Rural Older Adults Living Alone: Perspectives of Meals on Wheels Programs

Ensuring the safety and social well-being of rural populations, especially rural older adults living alone with complex medical conditions, is challenging, given large, sparsely populated communities and limited resources. Using qualitative data from surveys with 42 rural Meals on Wheels programs from across the U.S., we highlight particular challenges to meeting the social and safety needs of rural older adults living alone. Respondents described challenges, opportunities, and successes in meeting the needs of their clients. We describe these under four domains: main challenges, what can be done to address social isolation and loneliness, safety issues, improving safety, and current successes. We also identify cross-cutting themes related to programs' rural environment (long distances, inclement weather), infrastructure (housing quality, access to broadband Internet and technological connectivity, road conditions), funding and resource availability, and service provision (availability of health care and partner organizations.) We describe each of these in more detail and also share policy recommendations for improving health and safety of older adults living alone in rural areas, including funding nutrition programs as a health benefit and addressing aging, poor-quality housing stock.

"It's Like Finding Your Way Through the Labyrinth": a Qualitative Study of Veterans' Experiences Accessing Healthcare

BACKGROUND

The 2014 Veterans Choice Act and subsequent 2018 Veteran's Affairs (VA) Maintaining Systems and Strengthening Integrated Outside Networks Act (MISSION Act) are legislation which clarified Veteran access to healthcare provided by non-VA clinicians (community care). These policies are of particular importance to Veterans living in rural areas, who tend to live farther from VA medical facilities than urban Veterans.

OBJECTIVE

To understand Veterans' experiences of the MISSION Act and how it impacted their access to primary care to inform future interventions with a focus on reaching rural Veterans.

DESIGN

Qualitative descriptive design.

PARTICIPANTS

United States (US) Veterans in Northwestern states engaged in VA and/or community care.

APPROACH

Semi-structured interviews were conducted with a purposive sample of Veterans between August 2020 and September 2021. Interview domains focused on barriers and facilitators of healthcare access. Transcripts were analyzed using thematic analysis.

KEY RESULTS

We interviewed 28 Veterans; 52% utilized community care as their primary source of care and 36% were from rural or frontier areas. Three main themes emerged: (1) Veterans described their healthcare experiences as positive but also frustrating (billing and prior authorization were noted as top frustrations); (2) Veterans with medical complexities, living far from healthcare services, and/or seeking women's healthcare services experienced additional frustration due to increased touch points with VA systems and processes; and (3) financial resources and/or knowledge of the VA system insulated Veterans from frustration with healthcare navigation.

CONCLUSIONS

Despite provisions in the MISSION Act, Veteran participants described persistent barriers to healthcare access. Patient characteristics that required increased interaction with VA processes exacerbated these barriers, while financial resources and VA system knowledge mitigated them. Interventions to improve care coordination or address access barriers across VA and community care settings could improve access and reduce health inequities for Veterans-especially those with medical complexities, those living far from healthcare services, or those seeking women's healthcare.

Homebound older adults who live independently in rural Japan: Prevalence and contributing factors during the COVID-19 pandemic

Being homebound is a phenomenon of confining older adults to their homes owing to health, social, and psychological factors. During the COVID-19 pandemic, people were requested to refrain from going out to prevent infection. Consequently, the homebound status of older adults was influenced by social and environmental factors, resulting in an increase in the number of homebound older adults during the pandemic. This study aimed to determine the homebound prevalence and related factors among homebound older adults during the COVID-19 pandemic. In 2021, a cross-sectional study conducted in rural Saitama, Japan, included 1,020 participants aged 65 years and above who did not have long-term care insurance certification and were independent in instrumental activities of daily living. Herein, homebound individuals were defined as those who went out once a week or less. The relationships of homebound status with demographic, health, social, and psychological factors in older adults were examined. The prevalence of homebound independent older adults was estimated as 10.4 % (6.6 % males, 13.8 % females). Homebound status was significantly associated with one or more medical histories (odds ratio [OR] = 1.98, 95 % confidence interval [CI] = 1.00-3.90), no social or family roles (OR = 1.95, 95 % CI = 1.09-3.48), and no hobbies (OR = 1.84, 95 % CI = 1.02-3.34). Establishing social or family roles and promoting participation in hobbies may prevent older adults from being homebound. The social environment, which changed during the pandemic, should be improved to encourage older adults to go out.

Australian rural service learning student placements: a national survey

This preliminary national study is the first of its kind to investigate how service learning placements are implemented in real world settings in rural Australia and what factors enable or hinder their implementation. An anonymous survey was distributed to 17 University Departments of Rural Health (UDRH) in Australia. Numerical data were analysed descriptively. Textual data were analysed using a hybrid content analysis approach. Thirty seven respondents provided data representing 12 UDRHs. Responding UDRHs reported facilitating service learning programs, with experience in this context ranging from 3 months to 21 years. Service learning placements predominantly occurred in schools and aged care facilities. Occupational therapy, physiotherapy, and speech pathology were the most frequently involved professions in service learning. Enablers and barriers identified were categorised into: People, Partnerships, and Place and Space. This national-scale study provides a springboard for more in-depth investigation and implementation research focused on development of a conceptual model to support service learning across rural and remote Australia.

Implementing the European code of cancer practice in rural settings

Existing evidence often indicates higher cancer incidence and mortality rates, later diagnosis, lower screening uptake and poorer long-term survival for people living in rural compared to more urbanised areas. Despite wide inequities and variation in cancer care and outcomes across Europe, much of the scientific literature explicitly exploring the impact of rurality on cancer continues to come from Australia and North America. The European Code of Cancer Practice or "The Code" is a citizen and patient-centred statement of the most salient requirements for good clinical cancer practice and has been extensively co-produced by cancer patients, cancer professionals and patient advocates. It contains 10 key overarching Rights that a cancer patient should expect from their healthcare system, regardless of where they live and has been strongly endorsed by professional and patient cancer organisations as well as the European Commission. In this article, we use these 10 fundamental Rights as a framework to argue that (i) the issues and needs identified in The Code are generally more profound for rural people with cancer; (ii) addressing these issues is also more challenging in rural contexts; (iii) interventions and support must explicitly account for the unique needs of rural residents living with and affected by cancer and (iv) new innovative approaches are urgently required to successfully overcome the challenges faced by rural people with cancer and their caregivers. Despite equitable healthcare being a key European policy focus, the needs of rural people living with cancer have largely been neglected.

Accessing perinatal substance use disorder care in your local community: A case study of an innovative hub and spoke network in western North Carolina

INTRODUCTION

The incidence of substance use disorders (SUD) in the general population and in the pregnant person population has risen over the last 20 years. Concurrently, both perinatal and SUD care in rural areas is laden with access barriers including but not limited to geographical distance from potential treatment and stigma. An integrated outpatient perinatal substance use disorder (PSUD) clinic in an urban area in western North Carolina (WNC) found that patients who traveled further for prenatal care were less likely to continue seeking care in the postpartum period. Acknowledging that the risk of overdose increases in the postpartum period, the PSUD clinic utilized a hub and spoke model to promote healthcare accessibility.

METHODS

The clinic adapted the Vermont hub and spoke model and the CHARM (Children and Recovering Mothers) collaborative. The urban hub in WNC has now developed eight spokes in rural communities. The hub provides education and technical assistance to the rural spokes, and the two engage in bidirectional referral pathways. This manuscript details the model and analyzes the existing strengths and barriers at two spokes, a family medicine Federally Qualified Health Center and a hospital affiliated obstetrics and gynecology practice and analyzes their process of implementation of integrated outpatient perinatal substance use care.

RESULTS

Both spokes found coaching relationships and the sharing of resources such as clinical guidelines useful to begin prescribing buprenorphine for PSUD. Their context led one spoke to begin prescribing within one year while the other took two years.

CONCLUSION

Comparing and contrasting these spokes serves to demonstrate that across many contexts, a hub and spoke model is a replicable intervention for rural perinatal substance use access to care barriers. Comparing the two spokes emphasizes the need for adaptation as well as standardization of the model to improve evidence-based PSUD care most effectively.

Testing the feasibility of the QuitAid smoking cessation intervention in a randomized factorial design in an independent, rural community pharmacy

BACKGROUND

Adult smoking rates in the USA are highest in economically depressed rural Appalachia. Pharmacist-delivered tobacco cessation support that incorporates medication therapy management (such as the QuitAid intervention) is a promising approach to address this need.

METHODS

Twenty-four adult smokers recruited between September and November 2021 through an independent pharmacy in rural Appalachia were randomized in a non-blinded 2 × 2 × 2 factorial design to (1) pharmacist delivered QuitAid intervention (yes vs. no); (2) combination nicotine replacement therapy (NRT) gum + NRT patch (vs. NRT patch); and/or (3) 8 weeks of NRT (vs. standard 4 weeks). Participants received 4 weeks of NRT patch in addition to the components to which they were assigned. Participants completed baseline and 3-month follow-up assessments. Primary outcomes were feasibility of recruitment and randomization, retention, treatment adherence, and fidelity.

RESULTS

Participants were recruited in 7 weeks primarily through a referral process, commonly referred to as ask-advise-connect (61%). Participants were on average 52.4 years old, 29.2% were male and the majority were white (91.6%) and Non-Hispanic (91.7%). There was a high level of adherence to the interventions, with 85% of QuitAid sessions completed, 83.3% of the patch used, and 54.5% of gum used. Participants reported a high level of satisfaction with the program, and there was a high level of retention (92%).

CONCLUSIONS

This demonstration pilot randomized controlled study indicates that an ask-advise-connect model for connecting rural smokers to smoking cessation support and providing QuitAid for smoking cessation is feasible and acceptable among rural Appalachian smokers and independent pharmacists. Further investigation into the efficacy of a pharmacist-delivered approach for smoking cessation is needed.

TRIAL REGISTRATION

The trial was retrospectively registered at ClinicalTrials.gov. Trial #: NCT05649241.

Influence of practice location on prescribing, diabetes care, and colorectal cancer screening among Czech general practitioners during the COVID-19 pandemic

OBJECTIVES

The provision of primary health care was not interrupted during the coronavirus disease 2019 (COVID-19) pandemic in Czechia, although the capacity and resources of providers changed. We examined how the pandemic affected individual general practices throughout 2017-2021, focusing on differences between urban and rural practices.

METHODS

We analysed data from the largest health insurance company in Czechia, which provides care to 4.5 million people (60% of the population). We evaluated the prescription volume, diabetes care procedures, and faecal immunochemical test (FIT) in preventive care and new pandemic-related procedures (remote consultations, testing, and vaccinations). For the spatial distribution of practices, we adapted the Organisation for Economic Cooperation and Development typology.

RESULTS

We observed minimal declines in 2020 in the rate of prescribing (-1.0%) and diabetes care (-5.1%), with a rapid resumption in 2021, but a substantial decline in FIT (-17.8% in 2020) with slow resumption. Remote consultations were used by 94% of all practices regardless of location, with testing and vaccinations more commonly performed by rural general practitioners (GPs).

CONCLUSIONS

Primary care in Czechia rose to the challenge of the COVID-19 pandemic, as shown by the finding that the volume of healthcare services provided through primary care did not decrease across most of the monitored parameters. This study also confirmed that rural GPs provide more care in-house, both in terms of prescribing and procedures performed in their practices. Future studies will need to focus on preventive care, which the pandemic has dampened in GP practices in Czechia.

A rural interprofessional primary care team develops a school-based sex education program

Introduction

In French rural areas, getting information about sexual health and identifying health actors on the topic is difficult for teenagers. Despite national and international guidelines, school-based sex education programs remain insufficient in France. The aim of this project was to develop a school-based psycho-affective and sexual health program (PASHP) for teenagers, led by an interprofessional primary care team (IPCT) in Montval-sur-Loir (Sarthe) and to coordinate local stakeholders.

Method

The IPCT developed the PASHP using a community-based participatory research method. The first step identified the target population and its needs for sex education. The second step was to create a steering group to tailor PASHP interventions in a participatory way and to define the PASHP’s aims and execution arrangements. The third step aimed at carrying out the PASHP and getting stakeholders’ and the target population’s feedback.

Results

The PASHP, carried out in the 2020–2021 and 2021–2022 school years, included an intervention about contraception and sexually transmitted infections, artistic workshops on consent or gender stereotypes, group discussions, and an intervention about pornography to assist parents.

Conclusion

The PASHP developed and coordinated by the Montval-sur-Loir IPCT is innovative because of its organization. It coordinates local stakeholders, teenagers, and their parents in a disadvantaged rural area, respecting national guidelines on sex education.

Assessing Community Needs for Autism Spectrum Disorder: A Review of Rural/Frontier Needs Through Community Outreach With Developmental Pediatrics

Early intervention is known to improve long-term outcomes for individuals with autism spectrum disorder (ASD). Access barriers to care limit timely engagement with supportive services. This report characterized the community needs and supportive services for children and families with suspected or diagnosed ASD. Families and providers participating in outreach clinics identified available services and their attitudes about support for ASD diagnosis. Chart reviews provided referral history, insurance, and current services. Children were nearly 6 years old, 95% of families relied on public health insurance, whereas 50% reported traveling 11 miles or greater for supportive services. Most providers (83%) were medically trained in primary care and placed 1-5 referrals per month to a tertiary referral hospital. Providers reported travel difficulty as the primary reason for referring patients for evaluation. Multiple barriers for supportive services were identified, highlighting the importance to increase the capacity and availability of local ASD supportive services.

Making waves: The benefits and challenges of responsibly implementing wastewater-based surveillance for rural communities

The sampling and analysis of sewage for pathogens and other biomarkers offers a powerful tool for monitoring and understanding community health trends and potentially predicting disease outbreaks. Since the early months of the COVID-19 pandemic, the use of wastewater-based testing for public health surveillance has increased markedly. However, these efforts have focused on urban and peri‑urban areas. In most rural regions of the world, healthcare service access is more limited than in urban areas, and rural public health agencies typically have less disease outcome surveillance data than their urban counterparts. The potential public health benefits of wastewater-based surveillance for rural communities are therefore substantial - though so too are the methodological and ethical challenges. For many rural communities, population dynamics and insufficient, aging, and inadequately maintained wastewater collection and treatment infrastructure present obstacles to the reliable and responsible implementation of wastewater-based surveillance. Practitioner observations and research findings indicate that for many rural systems, typical implementation approaches for wastewater-based surveillance will not yield sufficiently reliable or actionable results. We discuss key challenges and potential strategies to address them. However, to support and expand the implementation of responsible, reliable, and ethical wastewater-based surveillance for rural communities, best practice guidelines and standards are needed.

Boot Camp Translation using Community-Engaged messaging for adolescent Vaccination: A Cluster-Randomized trial

BACKGROUND

Routine vaccination coverage for adolescents living in the rural US is lower than adolescents living in urban areas. We sought to measure the effect of Boot Camp Translation (BCT), a community-based participatory intervention, on rural adolescent vaccination coverage.

METHODS

A cluster randomized controlled trial was performed September 2018-November 2021 involving 16 rural Colorado counties. Intervention county community members engaged in BCT to develop interventions to improve adolescent vaccination locally. Adolescent vaccination coverage was measured using the Colorado Immunization Information System.

RESULTS

For 11-12-year-olds, HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage was lower post- versus pre-intervention in the control and intervention groups. For 11-12-year-olds in the intervention group, there was no significant difference post- versus pre-intervention in the odds of HPV vaccine initiation (adjusted ratio of odds ratios [aROR] = 0.93, 95 %: 0.85-1.02, p = 0.10) or up-to-date HPV vaccination (aROR: 1.10, 95 % CI: 0.98-1.23, p = 0.11) compared with the control group. Among 11-12-year-olds, the decrease in the proportion vaccinated with MenACWY and Tdap in the intervention group was significantly greater than the control group. Among 13-17-year-olds, there were significant increases in HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage from pre- to post-intervention for both groups, with no significant differences between groups.

CONCLUSION

11-12-year-old vaccination coverage decreased slightly from pre- to post-intervention while 13-17-year-old vaccination coverage increased. We saw no effect from the BCT intervention. Our findings about the effectiveness of BCT for improving vaccine uptake may not be generalizable because the study coincided with the COVID-19 pandemic.

CLINICAL TRIAL REGISTRY

This study was registered with ClinicalTrials.gov, NCT03955757.

Associations between metals and metabolomic profiles related to diabetes among adults in a rural region

INTRODUCTION

Exposure to metals is associated with increased risk of type 2 diabetes (T2D). Potential mechanisms for metals-T2D associations involve biological processes including oxidative stress and disruption of insulin-regulated glucose uptake. In this study, we assessed whether associations between metal exposure and metabolite profiles relate to biological pathways linked to T2D.

MATERIALS AND METHODS

We used data from 29 adults rural Colorado residents enrolled in the San Luis Valley Diabetes Study. Urinary concentrations of arsenic, cadmium, cobalt, lead, manganese, and tungsten were measured. Metabolic effects were evaluated using untargeted metabolic profiling, which included 61,851 metabolite signals detected in serum. We evaluated cross-sectional associations between metals and metabolites present in at least 50% of samples. Primary analyses adjusted urinary heavy metal concentrations for creatinine. Metabolite outcomes associated with each metal exposure were evaluated using pathway enrichment to investigate potential mechanisms underlying the relationship between metals and T2D.

RESULTS

Participants had a mean age of 58.5 years (standard deviation = 9.2), 48.3% were female, 48.3% identified as Hispanic/Latino, 13.8% were current smokers, and 65.5% had T2D. Of the detected metabolites, 455 were associated with at least one metal, including 42 associated with arsenic, 22 with cadmium, 10 with cobalt, 313 with lead, 66 with manganese, and two with tungsten. The metabolic features were linked to 24 pathways including linoleate metabolism, butanoate metabolism, and arginine and proline metabolism. Several of these pathways have been previously associated with T2D, and our results were similar when including only participants with T2D.

CONCLUSIONS

Our results support the hypothesis that metals exposure may be associated with biological processes related to T2D, including amino acid, co-enzyme, and sugar and fatty acid metabolism. Insight into biological pathways could influence interventions to prevent adverse health outcomes due to metal exposure.

The Impact of the Older Person's Grant Expansion on Hypertension Among Older Men in Rural South Africa: Findings From the HAALSI Cohort

Background and Objectives

Hypertension is a major modifiable contributor to disease burden in sub-Saharan Africa. We exploited an expansion to age eligibility for men in South Africa's noncontributory public pension to assess the impact of pension eligibility on hypertension in a rural, low-income South African setting.

Research Design and Methods

Data were from 1 247 men aged ≥60 in the population-representative Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa in 2014/2015. We identified cohorts of men from 0 (controls, aged ≥65 at pension expansion) through 5 years of additional pension eligibility based on their birth year. Using the modified Framingham Heart Study hypertension risk prediction model, and the Wand et al. model modified for the South African population, we estimated the difference in the probabilities of hypertension for men who benefitted from the pension expansion relative to the control. We conducted a negative control analysis among older women, who were not eligible for pension expansion, to assess the robustness of our findings.

Results

Older men with 5 additional years of pension eligibility had a 6.9-8.1 percentage point greater probability of hypertension than expected without the pension expansion eligibility. After accounting for birth cohort effects through a negative control analysis involving older women reduced estimates to a 3.0-5.2 percentage point greater probability of hypertension than expected. We observed a mean 0.2 percentage point increase in the probability of hypertension per additional year of pension eligibility, but this trend was not statistically significant.

Discussion and Implications

Although the Older Person's Grant is important for improving the financial circumstances of older adults and their families in South Africa, expanded pension eligibility may have a small, negative short-term effect on hypertension among older men in this rural, South African setting.

A systematic review on the qualitative experiences of people living with lung cancer in rural areas

PURPOSE

To synthesize the qualitative literature exploring the experiences of people living with lung cancer in rural areas.

METHODS

Searches were performed in MEDLINE, CINAHL, and PsycINFO. Articles were screened independently by two reviewers against pre-determined eligibility criteria. Data were synthesized using Thomas and Harden's framework for the thematic synthesis of qualitative research. The CASP qualitative checklist was used for quality assessment and the review was reported in accordance with the ENTREQ and PRISMA checklists.

RESULTS

Nine articles were included, from which five themes were identified: (1) diagnosis and treatment pathways, (2) travel and financial burden, (3) communication and information, (4) experiences of interacting with healthcare professionals, (5) symptoms and health-seeking behaviors. Lung cancer diagnosis was unexpected for some with several reporting treatment delays and long wait times regarding diagnosis and treatment. Accessing treatment was perceived as challenging and time-consuming due to distance and financial stress. Inadequate communication of information from healthcare professionals was a common concern expressed by rural people living with lung cancer who also conveyed dissatisfaction with their healthcare professionals. Some were reluctant to seek help due to geographical distance and sociocultural factors whilst others found it challenging to identify symptoms due to comorbidities.

CONCLUSIONS

This review provides a deeper understanding of the challenges faced by people with lung cancer in rural settings, through which future researchers can begin to develop tailored support to address the existing disparities that affect this population.

Clinical education models in rural practice settings: A scoping review

AIM

The objective of this review is to identify and synthesize the literature on clinical nursing education models in rural settings, with the goal of developing a better understanding of effective clinical education models suitable for rural nursing education.

BACKGROUND

Clinical education is an integral part of nursing education, yet very little clinical education occurs in rural and remote areas. This leaves the rural landscape vulnerable to inadequate health care staffing because many graduates will begin their nursing practice in the geographical areas where they studied. The rural nursing workforce is currently insufficient to meet the health care needs of rural populations. This insufficiency is likely to worsen because statistical trends suggest that rural and remote communities might be among the worst affected by the global nursing shortage. Many new graduate nurses are ill prepared for rural nursing practice, primarily due to limited exposure to rural nursing content and rural clinical experiences in their entry-to-practice education. Increasing opportunities for nursing students to learn in rural clinical settings will likely support the recruitment and retention of nurses in rural practice. Despite the key role of rural nursing education in sustaining the rural health workforce, little is known about rural clinical learning in nursing education.

DESIGN

A scoping review.

METHODS

This scoping review was conducted using the steps outlined by Arksey and O'Malley with updated methodological guidance from the Joanna Briggs Institute.

RESULTS

Of 1880 potential data sources, 82 were included in data analysis. Although no distinct model of rural clinical nursing education could be identified, several features of clinical nursing education were described in the context of rural clinical learning. Preceptorship was the most used mentorship/clinical supervision model (n=41). The most common placement design was a block model design (n=41) lasting between one and 16 weeks, with most learners engaging in episodic care with individual clients (n=42). Interestingly, 24 sources reported learners engaging in rural clinical education across multiple contexts (e.g., acute care, home care, and primary care).

CONCLUSION

These findings suggest there exists great variability in rural clinical learning opportunities for nursing students. Academic practice partnerships could continue to be leveraged to provide learners with rural clinical education that meets the needs of both the educational institution as well as the rural communities in which learning takes place. An area of further research would be to focus on formal evaluation of the effectiveness of clinical education models in the rural context.

Connectivity is the key to longer rural placement: Retaining students on rural longitudinal integrated clerkships

PURPOSE

Recruitment and retention of medical practitioners to rural practice is an ongoing global issue. Rural longitudinal integrated clerkships (LIC) are an innovative solution to this problem, which are known to increase rural workforce. Crucially this association increases with time on rural placement. This study examines factors that promote retention in a Rural LIC.

METHODS

A two-phased, sequential design qualitative study in a cohort of students enrolled in a rural LIC at Griffith University, Queensland, Australia. Phase I consisted of an open-ended questionnaire and phase II follow-up focus groups from the same cohort. Data was transcribed and analysed using an iterative, six-step thematic analysis process to identify salient themes.

RESULTS

Twenty-four students were invited to participate, of which eight respond in phase I and thirteen participated in phase II. Participants described retention being driven by connectivity within three broad themes: current practice, future practice (immediate internship and career intention), and social networks. Participant proposals to increase connectivity were also suggested including peer-led solutions and short rotations in metropolitan hospitals.

CONCLUSION

Connectivity is key to retention on rural longitudinal integrated clerkships. Programs which enhance connectivity with current practice, future practice, and social networks will increase retention on rural medical programs.

The impact of rural status on pediatric chronic kidney disease

Children and adolescents in rural areas with chronic kidney disease (CKD) face unique challenges related to accessing pediatric nephrology care. Challenges to obtaining care begin with living increased distances from pediatric health care centers. Recent trends of increasing centralization of pediatric care mean fewer locations have pediatric nephrology, inpatient, and intensive care services. In addition, access to care for rural populations expands beyond distance and encompasses domains of approachability, acceptability, availability and accommodation, affordability, and appropriateness. Furthermore, the current literature identifies additional barriers to care for rural patients that include limited resources, including finances, education, and community/neighborhood social resources. Rural pediatric kidney failure patients have barriers to kidney replacement therapy options that may be even more limited for rural pediatric kidney failure patients when compared to rural adults with kidney failure. This educational review identifies possible strategies to improve health systems for rural CKD patients and their families: (1) increasing rural patient and hospital/clinic representation and focus in research, (2) understanding and mediating gaps in the geographic distribution of the pediatric nephrology workforce, (3) introducing regionalization models for delivering pediatric nephrology care to geographic areas, and (4) employing telehealth to expand the geographic reach of services and reduce family time and travel burden.

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.

Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings.

METHODS

SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention's components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up.

DISCUSSION

Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT04890054) and at the NCI's Clinical Trials Reporting Program (CTRP no.: NCI-2021-01032) on May 11, 2021.

Stakeholder perspectives on a telemedicine referral and coordination model to expand medication treatment for opioid use disorder in rural primary care clinics

INTRODUCTION

Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor.

METHODS

We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale.

RESULTS

Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff.

CONCLUSIONS

Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

Investigating the Relationship Between Marital Status and Ethnicity on Neurocognitive Functioning in a Rural Older Population: A Project FRONTIER Study

OBJECTIVES

Research indicates being married is related to better physical and psychological health. Little is known regarding the relationship between marital status and neurocognitive functioning and whether it differs based on ethnicity (Hispanic vs non-Hispanic). This is the first study to examine this relationship in a sample of aging adults in rural Texas.

METHODS

Data from 1,864 participants (Mage = 59.68, standard deviation [SD]age = 12.21), who were mostly Hispanic (n = 1,053), women (n = 1,295), and married (n = 1,125) from Project Facing Rural Obstacles to Healthcare Now Through Intervention, Education, & Research were analyzed. Neuropsychological testing comprised Repeatable Battery for the Assessment of Neuropsychological Status, Trails Making Test, and Clock Drawing. Participants were dichotomized, married, and unmarried.

RESULTS

There was a significant interaction between Hispanic identity and marital status on overall neurocognitive functioning (F(1, 1,480) = 4.79, p < .05, ηp2 = 0.003). For non-Hispanic individuals, married individuals had higher overall neurocognitive functioning compared to unmarried individuals, whereas neurocognitive functioning for Hispanic individuals did not significantly differ between married and unmarried individuals. There were significant main effects as married individuals (M = 84.95, SD = 15.56) had greater overall neurocognitive functioning than unmarried individuals (M = 83.47, SD = 15.86; F(1, 1,480) = 14.67, p < .001, ηp2 = 0.01), Hispanic individuals (M = 78.02, SD = 14.25) had lower overall neurocognitive functioning than non-Hispanic individuals (M = 91.43, SD = 15.07; F(1, 1,480) = 284.99, p < .001, ηp2 = 0.16).

DISCUSSION

Hispanics living in rural areas experience additional stressors that could lead to worse neurocognitive functioning, which is supported by the Lifespan Biopsychosocial Model of Cumulative Vulnerability and Minority Health, which postulates that race/ethnicity/socioeconomic-status-related stressors exacerbate the impact of other life stressors. Reduction of stress on rural Hispanics should be a priority as it could positively affect their neurocognitive functioning.

Different meanings… what we want in our lives… a qualitative exploration of the experience of Aboriginal and/or Torres Strait Islander peoples in a co-designed community rehabilitation service

PURPOSE

Promoting positive psychological, social and functional health outcomes for Aboriginal and Torres Strait Islander people requires health services to be culturally safe, respecting culture as central to the individuals and their communities. This study explored the experience of Aboriginal and Torres Strait Islander people, participating in a co-designed student-assisted community rehabilitation service in a remote Aboriginal community in Far North Queensland.

MATERIALS AND METHODS

Observation, informal yarning and semi-structured interviews with older Aboriginal and Torres Strait Islander people (n = 6) engaged in the service was conducted over a 7 week period. Interpretive phenomenological analysis was applied through inductive thematic analysis.

RESULTS

Four themes illustrated that experiences within the program promoted: A connection to people, both within the program and those significant in people's lives; a connection to past experiences, roles and events; a connection to the future of cultural knowledge; and a sense of achievement and fun. Participants shared their unique stories on their positive experience of the culturally responsive approach in the activities.

CONCLUSIONS

These results suggest that knowledge translation and reciprocity provide a strong foundation for rehabilitation programs that support healthy ageing for Aboriginal and Torres Strait Islander people and encourage active and ongoing individual and community involvement.

Rural/nonrural sleep duration patterns among adults in middle and older adulthood

OBJECTIVES

To document sleep duration differences between rural and nonrural adults in middle/older adulthood.

METHODS

Data consisted of adults aged 50-80 from the 2014, 2016, 2018, and 2020 Behavioral Risk Factor Surveillance System (n = 669,978). Hierarchical multinomial logistic regression models were fit predicting self-reported short (ie, 6 or fewer hours per 24-hour period) and long (ie, 9 or more hours per 24-hour period) compared to normal-sleep duration (ie, 7-8hours per 24-hour period).

RESULTS

Rural adults aged 50+ had slightly but significantly lower levels of short sleep (30.0% vs. 30.8%), and slightly but significantly higher levels of long sleep (10.6% vs. 9.4%). In multinomial logistic models that accounted for demographics, rural adults had significantly higher levels of long sleep (OR 1.16, 95% CI 1.12-1.21). The long-sleep differences were explained by socioeconomic measures.

CONCLUSIONS

Sleep researchers should continue to investigate and conceptualize sleeping patterns and heterogeneity among rural adults.

Tools, frameworks and resources to guide global action on strengthening rural health systems: a mapping review

BACKGROUND

Inequities of health outcomes persist in rural populations globally. This is strongly associated with there being less health coverage in rural and underserviced areas. Increasing health care coverage in rural area requires rural health system strengthening, which subsequently necessitates having tools to guide action.

OBJECTIVE

This mapping review aimed to describe the range of tools, frameworks and resources (hereafter called tools) available globally for rural health system capacity building.

METHODS

This study collected peer-reviewed materials published in 15-year period (2005-2020). A systematic mapping review process identified 149 articles for inclusion, related to 144 tools that had been developed, implemented, and/or evaluated (some tools reported over multiple articles) which were mapped against the World Health Organization's (WHO's) six health system building blocks (agreed as the elements that need to be addressed to strengthen health systems).

RESULTS

The majority of tools were from high- and middle-income countries (n = 85, 59% and n = 43, 29%, respectively), and only 17 tools (12%) from low-income countries. Most tools related to the health service building block (n = 57, 39%), or workforce (n = 33, 23%). There were a few tools related to information and leadership and governance (n = 8, 5% each). Very few tools related to infrastructure (n = 3, 2%) and financing (n = 4, 3%). This mapping review also provided broad quality appraisal, showing that the majority of the tools had been evaluated or validated, or both (n = 106, 74%).

CONCLUSION

This mapping review provides evidence that there is a breadth of tools available for health system strengthening globally along with some gaps where no tools were identified for specific health system building blocks. Furthermore, most tools were developed and applied in HIC/MIC and it is important to consider factors that influence their utility in LMIC settings. It may be important to develop new tools related to infrastructure and financing. Tools that have been positively evaluated should be made available to all rural communities, to ensure comprehensive global action on rural health system strengthening.

Adolescent cancer prevention in rural, pediatric primary care settings in the United States: A scoping review

Adolescence is a critical period for establishing habits and engaging in health behaviors to prevent future cancers. Rural areas tend to have higher rates of cancer-related morbidity and mortality as well as higher rates of cancer-risk factors among adolescents. Rural primary care clinicians are well-positioned to address these risk factors. Our goal was to identify existing literature on adolescent cancer prevention in rural primary care and to classify key barriers and facilitators to implementing interventions in such settings. We searched the following databases: Ovid MEDLINE®; Ovid APA PsycInfo; Cochrane Library; CINAHL; and Scopus. Studies were included if they reported on provider and/or clinic-level interventions in rural primary care clinics addressing one of these four behaviors (obesity, tobacco, sun exposure, HPV vaccination) among adolescent populations. We identified 3,403 unique studies and 24 met inclusion criteria for this review. 16 addressed obesity, 6 addressed HPV vaccination, 1 addressed skin cancer, and 1 addressed multiple behaviors including obesity and tobacco use. 10 studies were either non-randomized experimental designs (n = 8) or randomized controlled trials (n = 2). The remaining were observational or descriptive research. We found a dearth of studies addressing implementation of adolescent cancer prevention interventions in rural primary care settings. Priorities to address this should include further research and increased funding to support EBI adaptation and implementation in rural clinics to reduce urban-rural cancer inequities.

Prioritizing rural populations in state comprehensive cancer control plans: a qualitative assessment

PURPOSE

The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) requires that states develop comprehensive cancer control (CCC) plans and recommends that disparities related to rural residence are addressed in these plans. The objective of this study was to explore rural partner engagement and describe effective strategies for incorporating a rural focus in CCC plans.

METHODS

States were selected for inclusion using stratified sampling based on state rurality and region. State cancer control leaders were interviewed about facilitators and barriers to engaging rural partners and strategies for prioritizing rural populations. Content analysis was conducted to identify themes across states.

RESULTS

Interviews (n = 30) revealed themes in three domains related to rural inclusion in CCC plans. The first domain (barriers) included (1) designing CCC plans to be broad, (2) defining "rural populations," and (3) geographic distance. The second domain (successful strategies) included (1) collaborating with rural healthcare systems, (2) recruiting rural constituents, (3) leveraging rural community-academic partnerships, and (4) working jointly with Native nations. The third domain (strategies for future plan development) included (1) building relationships with rural communities, (2) engaging rural constituents in planning, (3) developing a better understanding of rural needs, and (4) considering resources for addressing rural disparities.

CONCLUSION

Significant relationship building with rural communities, resource provision, and successful strategies used by others may improve inclusion of rural needs in state comprehensive cancer control plans and ultimately help plan developers directly address rural cancer health disparities.

Standardizing post-cardiac arrest care across rural-urban settings - qualitative findings on proposed post-cardiac arrest learning community intervention

BACKGROUND

Standardization of post-cardiac arrest care between emergency department arrival and intensive care unit admission can be challenging, particularly for rural centers, which can experience significant delays in interfacility transfer. One approach to addressing this issue is to form a post-cardiac arrest learning community (P-CALC) consisting of emergency department (ED) and intensive care unit (ICU) physicians and nurses who use data, shared resources, and collaboration to improve post-cardiac arrest care. MaineHealth, the largest regional health system in Maine, launched its P-CALC in 2022.

OBJECTIVE

To explore P-CALC participants' perspectives on current post-cardiac arrest care, attitudes toward implementing a P-CALC intervention, perceived barriers and facilitators to intervention implementation, and implementation strategies.

METHODS

We conducted semi-structured, individual, qualitative interviews with 16 staff from seven system EDs spanning the rural-urban spectrum. Directed content analysis was used to discern key themes in transcribed interviews.

RESULTS

Participants highlighted site- and system-level factors influencing current post-cardiac arrest care. They expressed both positive attitudes and concerns about the P-CALC intervention. Multiple facilitators and barriers were identified in regard to the intervention implementation. Five proposed implementation strategies emerged as important factors to move the intervention forward.

CONCLUSIONS

Implementation of a P-CALC intervention to effect system-wide improvements in post-cardiac arrest care is complex. Understanding providers' perspectives on current care practices, feasibility of quality improvement, and potential intervention impacts is essential for program development.

Healthy eating and active living policy, systems, and environmental changes in rural Louisiana: a contextual inquiry to inform implementation strategies

BACKGROUND

Healthy eating and active living policy, systems, and environmental (PSE) changes are implemented across the United States through Cooperative Extension. However, translating multisector PSE changes to practice in community settings is challenging and there is a lack of knowledge about barriers and facilitators to PSE changes among state Extension systems using standardized frameworks. Therefore, a research-to-practice partnership effort aimed to identify Louisiana Cooperative Extension Service Family and Consumer Science (LFCS) practitioners' barriers and facilitators to implementing PSE changes in rural Louisiana communities.

METHODS

A qualitative approach using the 2022 Consolidated Framework for Implementation Research (2022 CFIR) was used. Focus group discussions were conducted at five LFCS regional trainings between February and May 2022. All LFCS practitioners with any level of experience implementing healthy eating and active living PSE changes were eligible to participate, with emphasis on understanding efforts within more rural communities. Focus group discussions were audio-recorded and transcribed verbatim. Researchers analyzed qualitative data using the constant comparison method and 2022 CFIR domains and constructs including Inner Setting (LFCS organization), Outer Setting (rural Louisiana communities), Innovation (PSE changes), and Individuals (PSE change implementation actors/partners).

RESULTS

Across the five regions, LFCS practitioners (n = 40) described more barriers (n = 210) than facilitators (n = 100); findings were often coded with multiple 2022 CFIR domains. Reported Inner Setting barriers were lack of formal or informal information sharing and lack of access to knowledge and information. Outer Setting barriers included sustaining and initiating community partnerships and local environmental or political conditions. Individual barriers included a lack of time and expertise, and Innovation barriers included the complex nature of rural PSE changes. Facilitators were mentioned at multiple levels and included community partner buy-in and practitioners' motivation to implement PSE changes.

CONCLUSIONS

Implementation strategies are needed to build on organizational strengths and to overcome multi-level barriers to PSE change implementation among LFCS practitioners. The results from the in-depth contextual inquiry used could serve as a guide for future pragmatic assessment efforts among other state Extension systems or as a model for identifying barriers and facilitators and associated implementation strategies among other public health systems in the U.S. and abroad.