Discussions of Cancer Survivorship Care Needs: Are There Rural Versus Urban Inequities?

BACKGROUND: Rural cancer survivors may face greater challenges receiving survivorship care than urban cancer survivors. PURPOSE: To test for rural versus urban inequities and identify other correlates of discussions about cancer survivorship care with healthcare professionals. METHODS: Data are from the 2017 Medical Expenditure Panel Survey (MEPS), which included a cancer survivorship supplement. Adult survivors were asked if they discussed with a healthcare professional 5 components of survivorship care: need for follow-up services, lifestyle/health recommendations, emotional/social needs, long-term side effects, and a summary of treatments received. The Behavioral Model of Health Services guided the inclusion of predisposing, enabling, and need factors in ordered logit regression models of each survivorship care variable. RESULTS: A significantly lower proportion of rural than urban survivors (42% rural, 52% urban) discussed in detail the treatments they received, but this difference did not persist in the multivariable model. Although 69% of rural and 70% of urban ssurvivors discussed in detail their follow-up care needs, less than 50% of both rural and urban survivors discussed in detail other dimensions of survivorship care. Non-Hispanic Black race/ethnicity and time since treatment were associated with lower odds of discussing 3 or more dimensions of survivorship care. CONCLUSIONS: This study found only a single rural/urban difference in discussions about survivorship care. With the exception of discussions about the need for follow-up care, rates of discussing in detail other dimensions of survivorship care were low among rural and urban survivors alike.

Impact of Medicaid Expansion on Medicaid-covered Utilization of Buprenorphine for Opioid Use Disorder Treatment.

BACKGROUND: Buprenorphine has been proven effective in treating opioid use disorder. However, the high cost of buprenorphine and the limited prescribing capacity may restrict access to this effective medication-assisted treatment for opioid use disorder. OBJECTIVE: To examine whether Medicaid expansion and physician prescribing capacity may have impacted buprenorphine utilization covered by Medicaid. RESEARCH DESIGN: We used a quasi experimental difference-in-differences design to compare the pre-post changes in Medicaid-covered buprenorphine prescriptions and buprenorphine spending between the 26 states that implemented Medicaid expansions under the Affordable Care Act in 2014 and those that did not. SUBJECTS: All Medicaid enrollees in the expansion states and the nonexpansion and late-expansion states. MEASURES: Quarterly Medicaid prescriptions for buprenorphine and spending on buprenorphine from the Centers for Medicare and Medicaid Services Medicaid Drug Utilization files 2011 to 2014. RESULTS: State implementation of Medicaid expansions in 2014 was associated with a 70% increase (P<0.05) in Medicaid-covered buprenorphine prescriptions and a 50% increase (P<0.05) in buprenorphine spending. Physician prescribing capacity was also associated with increased buprenorphine utilization. CONCLUSIONS: Medicaid expansion has the potential to reduce the financial barriers to buprenorphine utilization and improve access to medication-assisted treatment of opioid use disorder. Active physician participation in the provision of buprenorphine is needed for ensuring that Medicaid expansion achieves its full potential in improving treatment access.

Acceptability of HIV Testing Sites Among Rural and Urban African Americans Who Use Cocaine.

African Americans (AAs) who use cocaine in the Southern region of the U.S. have a relatively high risk of HIV and need for HIV testing. Among this group, those residing in rural areas may have less favorable opinions about common HIV testing sites, which could inhibit HIV testing. We examined rural/urban variations in their acceptability of multiple HIV testing sites (private physician clinic, local health department, community health center, community HIV fair, hospital emergency department, blood plasma donation center, drug abuse treatment facility, and mobile van or community outreach worker). Results from partial proportional odds and logistic regression analyses indicate that rural AA who use cocaine have lower odds of viewing local health departments (OR = 0.09, 95 % CI = 0.03-0.21), physician offices (OR = 0.19, 95 % CI = 0.09-0.42), and drug use treatment centers (OR = 0.49; 95 % CI = 0.30-0.80) as acceptable relative to their urban counterparts. The findings have implications for further targeting HIV testing toward AAs who use of cocaine, particularly those residing in the rural South.

The Role of Social Capital in African Americans' Attempts to Reduce and Quit Cocaine Use.

BACKGROUND: Research examining substance users' recovery has focused on individual-level outcomes while paying limited attention to the contexts within which individuals are embedded, and the social processes involved in recovery. OBJECTIVES: This paper examines factors underlying African American cocaine users' decisions to reduce or quit cocaine use and uses practice theory to understand how lifestyle changes and shifts in social networks facilitate access to the capital needed to change cocaine use patterns. METHODS: The study, an in-depth analysis of substance-use life history interviews carried out from 2010 to 2012, included 51 currently not-in-treatment African American cocaine users in the Arkansas Mississippi Delta region. A blended inductive and deductive approach to data analysis was used to examine the socio-cultural and economic processes shaping cocaine use and recovery. RESULTS: The majority of participants reported at least one lifetime attempt to reduce or quit cocaine use; motivations to reduce use or quit included desires to meet social role expectations, being tired of using, and incarceration. Abstinence-supporting networks, participation in conventional activities, and religious and spiritual practices afforded access to capital, facilitating cocaine use reduction and sobriety. CONCLUSIONS: Interventions designed to increase connection to and support from nondrug using family and friends with access to recovery capital (e.g., employment, faith community, and education) might be ideal methods to reduce substance use among minorities in low-income, resource-poor communities.

The Criminal Justice Experience of African American Cocaine Users in Arkansas.

BACKGROUND: African Americans are incarcerated at rates much higher than other racial and ethnic groups in the United States. OBJECTIVES: We sought to qualitatively explore the relationships between ongoing involvement in the criminal justice system and continued drug use in a population of urban and rural African American cocaine users in a southern state. METHODS: Semi-structured qualitative interviews were conducted among African American cocaine users in Arkansas between 2010 and 2012. Participants resided in both rural (two counties located in the eastern Arkansas Mississippi delta region) and urban (the county including the capital city of Little Rock) areas. RESULTS: Numerous important themes emerged from participants' narratives, including chronic involvement with the criminal justice system (being a "career criminal"), continued access to drugs while incarcerated, relapse, and reincarceration and lack of access to effective drug treatment. Conclusion/Importance: The themes which emerged from our data speak to the collective experience that many substance using populations in the United States face in dealing with the criminal justice system. Our findings highlight the need to better, more holistic ways of engaging African American substance users in community based substance use treatment and supportive services.

Correlates of HIV testing among rural African American cocaine users.

Andersen's Revised Behavioral Model of Health Services Use (RBM) was used as a framework in this correlational cross-sectional study to examine factors associated with HIV testing among a sample of 251 rural African American cocaine users. All participants reported using cocaine and being sexually active within the past 30 days. Independent variables were categorized according to the RBM as predisposing, enabling, need, or health behavior factors. Number of times tested for HIV (never, one time, two to four times, five or more times) was the outcome of interest. In ordered logistic regression analyses, HIV testing was strongly associated with being female, of younger age (predisposing factors); having been tested for sexually transmitted diseases or hepatitis, ever having been incarcerated in jail or prison (enabling factors); and having had one sex partner the past 30 days (health behavior factor). Other sexual risk behaviors, drug use, health status, and perception of risk were not associated with HIV testing. Our findings confirm the importance of routine testing in all healthcare settings rather than risk-based testing.

The Religious and Spiritual Dimensions of Cutting Down and Stopping Cocaine Use: A Qualitative Exploration Among African Americans in the South.

This study qualitatively examines the religious and spiritual dimensions of cutting down and stopping cocaine use among African Americans in rural and urban areas of Arkansas. The analyses compare and contrast the narrative data of 28 current cocaine users living in communities where the Black church plays a fundamental role in the social and cultural lives of many African Americans, highlighting the ways that participants used religious symbols, idiomatic expression, and Biblical scriptures to interpret and make sense of their substance-use experiences. Participants drew on diverse religious and spiritual beliefs and practices, including participation in organized religion, reliance on a personal relationship with God, and God's will to cut down and stop cocaine use. Our findings suggest that culturally sensitive interventions addressing the influence of religion and spirituality in substance use are needed to reduce cocaine use and promote recovery in this at-risk, minority population.

Satisfaction With Care Among Cancer Survivors With Medicare Coverage: Are There Rural Versus Urban Inequities?

INTRODUCTION: Rural cancer survivors often face greater barriers to treatment, which may translate into worse satisfaction with health care. OBJECTIVE: To examine rural versus urban differences in satisfaction with health care among Medicare cancer survivors. METHODS: Data are from the 2020 Medicare Current Beneficiary Survey (MCBS). Rao-Scott chi-square analyses were conducted to examine rural versus urban inequities in satisfaction with 9 dimensions of health care (health professionals' concern for health, information about what was wrong, ease/convenience from home, ease of obtaining answers over telephone, getting needs taken care of at same location, availability of specialists, overall quality, and out-of-pocket costs, and availability of care at night/on weekends). Multiple logistic regression analyses were conducted to test for rural/urban differences while adjusting for race/ethnicity, gender, marital status, educational attainment, health insurance (traditional Medicare, Medicare Advantage, dual Medicaid coverage, employer, or self-purchased insurance), and self-rated overall health. RESULTS: Rural cancer survivors were less satisfied with the ease/convenience of getting to health professionals (93.35% rural and 96.87% urban) and less satisfied with getting all health care needs taken care of at the same location (88.32% rural and 92.22% urban). These rural/urban differences persisted when adjusting for other factors. CONCLUSIONS: Health care providers serving rural areas may need to consider new strategies to satisfy some of the unique needs of rural cancer survivors, such as better organizing services at single clinic sites and utilizing telehealth when feasible to reduce the need to travel for in-person services.

Cervical Cancer Screening Rates Among Rural and Urban Females, From 2019 to 2022.

Importance: Little nationally representative research has examined Papanicolaou testing rates from before the pandemic in 2019 through the COVID-19 pandemic in 2022. Papanicolaou testing rates among rural females are a concern as they have historically had lower screening rates than their urban counterparts. Objective: To examine the receipt of a Papanicolaou test in the past year among US females overall and females residing in rural and urban areas in 2019, 2020, and 2022. Design, Setting, and Participants: This repeated cross-sectional study used data from 3 years of the Health Information National Trends Survey (HINTS), a nationally representative survey that asks respondents about cancer screenings, sources of health information, and health and health care technologies. Study participants were females aged 21 to 65 years. Individuals who received a Papanicolaou test more than 1 to 3 years prior to a HINTS interview were excluded as they were likely not due for a Papanicolaou test. Exposures: Survey year (2019, 2020, and 2022) and rural or urban residence were the main exposure variables. Main Outcomes and Measures: Self-reported receipt of a Papanicolaou test within the past year. Results: Among the 188 243 531 (weighted; 3706 unweighted) females included in the analysis, 12.5% lived in rural areas and 87.5% in urban areas. Participants had a mean (SE) age of 43.7 (0.27) years and were of Hispanic (18.8%), non-Hispanic Asian (5.2%), non-Hispanic Black (12.2%), non-Hispanic White (59.6%), or non-Hispanic other (4.1%) race and ethnicity. In 2022, unadjusted past-year Papanicolaou testing rates were significantly lower among rural vs urban residents (48.6% [95% CI, 39.2%-58.1%] vs 64.0% [95% CI, 60.0%-68.0%]; P < .001). Adjusted odds of past-year Papanicolaou testing were lower in 2022 than 2019 (odds ratio, 0.70; 95% CI, 0.52-0.95; P = .02). Conclusions and Relevance: This repeated cross-sectional study found that past-year Papanicolaou testing rates were lower in 2022 than 2019, pointing to a need to increase access to screenings to prevent an uptick in cervical cancer incidence. Rural-vs-urban differences in 2022 indicate a need to specifically target rural females.

Risky sex in rural America: longitudinal changes in a community-based cohort of methamphetamine and cocaine users.

BACKGROUND AND OBJECTIVES: This study examined the longitudinal associations between stimulant use and sexual behaviors. METHODS: Data are from a 3-year community-based study of 710 rural stimulant users. Past 30-day crack cocaine, powder cocaine, and methamphetamine use and sexual behaviors (any sex, inconsistent condom use, and multiple sexual partners) were assessed through in-person interviews every 6 months. RESULTS: GEE analyses revealed that the odds of having sex remained steady over time, with crack cocaine and methamphetamine use positively associated with having sex. The odds of multiple sexual partners declined, but the odds of inconsistent condom use remained steady over time. Crack cocaine use was positively associated with multiple sexual partners, whereas powder cocaine use was negatively associated with inconsistent condom use. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Many rural stimulant users could potentially benefit from safe sex educational programs. Such efforts could reduce the incidence of HIV and other STIs in rural America.

Colorectal Cancer Screening in Rural and Urban Primary Care Practices Amid Implementation of the Medicare Access and CHIP Reauthorization Act.

PURPOSE: The Medicare Access and CHIP Reauthorization Act (MACRA) incentivized primary care practices to improve colorectal cancer screening rates. This study examined if colorectal screening rates improved among rural and urban primary care practices amid implementation of MACRA. METHODS: Colorectal cancer screening data are from a national registry of 139 primary care practices. Repeated measures regression tested for rural/urban differences and changes in screening rates between 2016 and 2020, adjusting for county demographic factors and social deprivation. RESULTS: Screening rates were 64% in both rural and urban practices in the first quarter of 2016 and increased to 80% and 83% in rural and urban practices, respectively, in the last quarter of 2020. In adjusted analyses, screening rates increased by 4% per year and there were no rural/urban differences. Lower screening rates were associated with higher county proportions of persons who were 45 to 74 years of age and Hispanic. Higher screening rates were associated with higher county proportions of persons who were White, Black, and Asian and higher social deprivation. CONCLUSIONS: Colorectal screening rates improved among rural and urban primary care practices during implementation of MACRA, but disparities persist among practices serving county populations that are relatively older, more Hispanic, and have higher social deprivation.

Physical victimization of rural methamphetamine and cocaine users.

Substance use and physical violence often coincide, but little has been published on the correlates associated with receipt of partner versus nonpartner physical violence for rural users of methamphetamine and/or cocaine. In this study, participants' substance use, depression and past-year physical victimization were assessed. In separate logistic regression models, received partner violence in females was associated with age; alcohol, cocaine, and methamphetamine abuse/dependence; and number of drugs used in the past 6 months. In males, received nonpartner violence was associated with age, cocaine abuse/dependence, and being Caucasian. Findings suggest a relationship between stimulant use and received violence among rural substance users and a need for victimization screenings in settings where such individuals seek health care.

Practice Predictors of Buprenorphine Prescribing by Family Physicians.

INTRODUCTION: Both opioid use disorder and mortality for opioid overdoses are increasing. Family physicians (FPs) can treat opioid use disorder if they are waivered to prescribe buprenorphine. Our objective was to determine personal, practice, and community characteristics associated with FPs prescribing buprenorphine. METHODS: We used data from the 2017 and 2018 American Board of Family Medicine examination registration questionnaire. The questionnaire asked about current prescribing of buprenorphine, as well as about practice size, organization, and location. Logistic regression was used to determine associations between buprenorphine treatment and individual, practice, and county characteristics. RESULTS: The questionnaire had a 100% response rate. After excluding FPs in noncontinuity practices and those who could not be linked to a US county, our final sample was 2726. Only 161 (5.9%) prescribed buprenorphine. Practice in a Federal Qualified Health Center (adjusted Odds Ratio [aOR] = 1.98 (95% CI, 1.08, 3.63)), in solo practice (aOR = 2.60 (1.38, 4.92)), or with a mental health professional (aOR = 2.70 (1.73, 4.22)) were positively associated with prescribing buprenorphine. Practice in a rural county or in a whole county mental health professional shortage area were not associated with buprenorphine prescribing. DISCUSSION: Few FPs prescribed buprenorphine, but those in practice settings with supporting mental health services were more likely to prescribe. With their training in the biopsychosocial model and a more even distribution across the rural continuum, FPs are perfectly situated to meet the increasing need for medication-assisted treatment. However, ensuring they have supporting mental health services will be central to having more FPs provide medication-assisted treatment.

Trends In Buprenorphine Prescribing By Physician Specialty.

Office-based visits involving a buprenorphine prescription increased significantly among primary care and specialist physicians from 2006 to 2014. The growing involvement of nonpsychiatry physicians in buprenorphine prescribing has the potential to provide better access to care for people with opioid use disorders.

What Is Rural? Challenges And Implications Of Definitions That Inadequately Encompass Rural People And Places.

Monitoring and improving rural health is challenging because of varied and conflicting concepts of just what rural means. Federal, state, and local agencies and data resources use different definitions, which may lead to confusion and inequity in the distribution of resources depending on the definition used. This article highlights how inconsistent definitions of rural may lead to measurement bias in research, the interpretation of research outcomes, and differential eligibility for rural-focused grants and other funding. We conclude by making specific recommendations on how policy makers and researchers could use these definitions more appropriately, along with definitions we propose, to better serve rural residents. We also describe concepts that may improve the definition of and frame the concept of rurality.

Longitudinal changes in methamphetamine and cocaine use in untreated rural stimulant users: racial differences and the impact of methamphetamine legislation.

AIMS: To examine how race and methamphetamine legislation are associated with changes in cocaine and methamphetamine use among untreated rural stimulant users. DESIGN: A longitudinal study of stimulant users identified through respondent-driven sampling. SETTING: Rural areas of three US states. PARTICIPANTS: Participants at baseline were current users of methamphetamine and/or cocaine. MEASURES: Self-reports of methamphetamine, crack cocaine and powder cocaine use were assessed at 6-month intervals over a 2-year period. Generalized estimating equations were performed to account for correlations between the repeated measurements. FINDINGS: Compared to whites, African Americans were much more likely to use crack cocaine, equally likely to use powder cocaine and much less likely to use methamphetamine. Both whites and African Americans reduced their consumption of methamphetamine and both forms of cocaine over 2 years. Exposure to laws restricting the purchase of over-the-counter cold medications containing methamphetamine precursors was not associated with methamphetamine use, but associated with a slight rise in powder and crack cocaine use. CONCLUSIONS: The study yielded disconcerting as well as promising findings regarding the natural history of stimulant use in rural areas. Of some concern is that methamphetamine precursor laws were correlated with increased cocaine consumption, diminishing their net public health benefits. However, despite its insurgence in rural areas of the United States, very few African Americans have initiated methamphetamine use. Regardless of race, many stimulant users stopped using cocaine and methamphetamine without formal substance abuse treatment over 24 months.

Does being an immigrant make a difference in seeking physician services?

The current study investigated the effects of immigration status, acculturation, and health beliefs on the use of preventive and non-preventive visits, through use of a nationally representative sample of U.S.-born and foreign-born adults. U.S.-born adults were found to have significantly more preventive and non-preventive visits than immigrants. The effects on predicting preventive visits of education, having a usual source of care, and having other public insurance were stronger among immigrants than among the U.S.-born. Health confidence and believing in the need for health insurance significantly predicted the numbers of both preventive and non-preventive visits among the U.S.-born but correlated little with either type of visit among immigrants. Among immigrant adults, acculturation affected only the number of preventive visits. The lower utilization of both preventive and non-preventive care among immigrants may be associated with a combination of better health and more limited enabling resources.

Correlates of intent to seek unnecessary pap tests among elderly women.

PURPOSE: Cervical cancer screening may be over-used by elderly women who might not benefit from the test. The purpose of this study was to examine the relative importance of objective factors (e.g. intact cervix) and subjective factors (e.g. patients' Pap-smear related beliefs/attitudes) as correlates of elderly women's intention to have a Pap smear. METHODS: This study was a secondary data analysis using a subset sample of the elderly women (>or=65 years) who participated in the Texas Tech 5000 Survey Wave 4, a cross-sectional phone interview study conducted in 2002. Intent to have a Pap test, previous gynecologic history, and beliefs/attitudes related to Pap tests were measured. chi2 tests and logistic regression were conducted. RESULTS: Among the 1,044 women in the analytical sample, 70.2% (733) reported intending to have a Pap smear test within the next 2 years. About 77% (449/582) of the women who had not undergone a hysterectomy reported the intend to have a Pap smear, whereas 62% (284/462) of the women who had undergone a hysterectomy reported the same intent (chi 2 = 30.26; df = 1; p = .000). Among women who had undergone a hysterectomy, having received a Pap smear within the past 2 years (odds ratio OR, 21.32; 95% confidence interval [CI], 11.52-39.47), perceiving that their doctors might feel having the test is a good idea (OR, 7.14; 95% CI, 3.15-16.19), and insurance covering the test (OR, 2.21; 95% CI, 1.18-4.15) were positive correlates of intent to have a Pap test. Among women who had not undergone a hysterectomy, previous Pap smear history (OR, 19.28; 95% CI, 10.15-37.10), perceived doctor's opinion (OR, 5.39; 95% CI, 2.38-12.19), perceived pain of the test (OR, 0.52; 95% CI, .28-.99), perceived importance (OR, 4.00; 95% CI, 1.32-12.10), and perceived risk of developing cervical cancer (OR, 4.27; 95% CI, 1.27-14.33) were correlates. CONCLUSIONS: Public health educational messages intended to increase appropriate use of Pap screening should include factual information about risk factors such as age and possession of an intact cervix. Other messages intended to reduce inappropriate use of Pap screening should be directed at physicians, since many elderly women intend to inappropriately seek Pap tests based on erroneous beliefs/attitudes.

Rural, suburban, and urban variations in alcohol consumption in the United States: findings from the National Epidemiologic Survey on Alcohol and Related Conditions.

CONTEXT: Alcohol consumption is a major public health problem nationally, but little research has investigated drinking patterns by rurality of residence. PURPOSE: To describe the prevalence of abstinence, alcohol use disorders, and risky drinking in rural, suburban, and urban areas of the United States. METHODS: Analyses of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were conducted to estimate prevalence rates for abstinence, a current alcohol use disorder, and exceeding recommended daily and weekly drinking limits. Logistic regression analyses were conducted to test for rural and urban versus suburban differences after adjusting for potential confounders. Additional analyses were stratified by Census Region. FINDINGS: Nationally, the odds of abstinence and, among drinkers, the odds of a current alcohol disorder and exceeding daily limits were higher in rural than suburban areas. Stratified analyses revealed differences in the associations between rurality of residence and drinking across Census Regions. Rural residents of the Northeast, Midwest, and South and urban residents of the Northeast had higher odds of abstinence than their suburban peers. Among drinkers, rural and urban residents of the Midwest had higher odds of a current alcohol disorder and exceeding daily limits; urban residents of the Midwest had higher odds of exceeding weekly limits. CONCLUSIONS: Abstinence is particularly common in the rural South, whereas alcohol disorders and excessive drinking are more problematic in the urban and rural Midwest. Health policies and interventions should be further targeted toward those places with higher risks of problem drinking.

Research on rural residence and access to drug abuse services: where are we and where do we go?

CONTEXT: Illicit drug use is common in rural areas, but very little research has investigated rural populations' access to drug abuse services. PURPOSE: To describe the current state of the scientific literature on access to drug abuse services in rural areas and suggest directions for future research. METHODS: We performed a literature review of published articles on rural drug abuse services and summarized the findings according to potential, realized, accommodating, and acceptable access. Relevant articles on rural access to medical, alcohol, and mental health care were selected to supplement the scarce literature specific to drug abuse. FINDINGS: A limited body of work indicates that rural populations have lower availability and utilize needed drug abuse services less frequently than their urban counterparts. Even less is known about the accommodation and acceptability of drug abuse programs serving rural populations. CONCLUSIONS: Research that investigates the existence and determinants of problems with access to drug abuse services is greatly needed to enable policy makers, drug treatment managers, and practitioners to better meet the needs of their rural clientele. As this field of inquiry advances, methodologies for constructing drug abuse service areas and measuring consumers' evaluations must be developed.