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

PURPOSE: The objective of this study is to identify how predisposing characteristics, enabling factors, and health needs are jointly and individually associated with epidemiological patterns of outpatient healthcare utilization for patients who already interact and engage with a large healthcare system. METHODS: We retrospectively analyzed electronic medical record data from 1,423,166 outpatient clinic visits from 474,674 patients in a large healthcare system from June 2018-March 2019. We evaluated patients who exclusively visited rural clinics versus patients who exclusively visited urban clinics using Chi-square tests and the generalized estimating equation Poisson regression methodology. The outcome was healthcare use defined by the number of outpatient visits to clinics within the healthcare system and independent variables included age, gender, race, ethnicity, smoking status, health status, and rural or urban clinic location. Supplementary analyses were conducted observing healthcare use patterns within rural and urban clinics separately and within primary care and specialty clinics separately. FINDINGS: Patients in rural clinics vs. urban clinics had worse health status [χ2 = 935.1, df = 3, p<0.0001]. Additionally, patients in rural clinics had lower healthcare utilization than patients in urban clinics, adjusting for age, race, ethnicity, gender, smoking, and health status [2.49 vs. 3.18 visits, RR = 0.61, 95%CI = (0.55,0.68), p<0.0001]. Further, patients in rural clinics had lower utilization for both primary care and specialty care visits. CONCLUSIONS: Within the large healthcare system, patients in rural clinics had lower outpatient healthcare utilization compared to their urban counterparts despite having potentially elevated health needs reflected by a higher number of unique health diagnoses documented in their electronic health records after adjusting for multiple factors. This work can inform future studies exploring the roots and ramifications of rural-urban healthcare utilization differences and rural healthcare disparities.

Physical activity, benefits, and barriers across the aging continuum.

BACKGROUND: A growing body of evidence indicates the importance of physical activity during midlife period linked to the likelihood of healthy aging, while the likelihood of an individual engaging in physical activity depends largely on their perceived benefits and barriers to being physically active. AIM: This study was to examine physical activity levels of midlife Korean American adults and their perceived benefits and barriers to physical activity compared with young and older adults. METHODS: We conducted a secondary analysis of data collected for a larger descriptive, cross-sectional study that was conducted with a sample of 517 Korean American adults in a Midwestern city. Data were collected using a survey questionnaire. RESULTS: A little more than half of the sample were women (57.1%), with a mean age of 41.6 (±â€¯13.4). The study sample met the current guidelines for physical activity far less than the general U.S. population (30.4% -34.6 vs. 51.7%). Less midlife adults met the guidelines for moderate-intensity physical activity than older adults (34.2% vs. 57.4%), while less midlife adults met the guidelines for vigorous-intensity physical activity than young adults (24.8% vs. 40.6%). Midlife adults perceived fewer benefits than did young and older adults. CONCLUSION: The findings indicate that midlife adults are less likely to engage in physical activity and probably more at risk for unhealthy ageing than young and older adults. Understanding benefits and barriers of target population is the first step in developing culturally and age-appropriate intervention to promote physical activity.

Ethnic differences in medicinal plant use among University students: a cross-sectional survey of self-reported medicinal plant use at two Midwest Universities.

BACKGROUND: Numerous surveys of medicinal plant use among college students abound, but none compare use between students enrolled in two different Universities with significantly different ethnic compositions. The objective of this study is to compare medicinal plant use between two different ethnic college populations and explore differences between student medicinal plant users and non-users for comparison with previous research. METHODS: Students (n = 721) at a large research university (n = 498) and a Pan-Tribal University for Native Americans (n = 233) completed surveys in October 2011 to assess past year medicinal plant use. The Mann-Whitney U test, Chi Square test, and General Linear Model were used to compare demographics and self-reported use of medicinal plants among students at both Universities and between past year users and non-users. RESULTS: Over 23% of university students surveyed reported past year medicinal plant use. Users were more likely to use commercial tobacco products and to report poorer health than non-users. While Native American student medicinal plant users reported significantly higher rates of commercial tobacco use, lower self-assessment of health, and less use of prescription medicine than non-Native users, no significant differences in prevalence of medicinal plant use were found between University student populations. CONCLUSIONS: Results are consistent with preexisting data showing higher rates of medicinal plant use among college students compared to the larger US population of adults and demonstrate previously documented health disparities in Native American populations compared to non-Native Americans.

Alcohol dependence and reproductive timing in African and European ancestry women: findings in a midwestern twin cohort.

OBJECTIVE: We examined associations between reproductive onset and history of alcohol dependence (AD) in 475 African ancestry (AA) and 2,865 European or other ancestry (EA) female twins. METHOD: Participants were drawn from a U.S. midwestern birth cohort study of like-sex female twin pairs born between 1975 and 1985, ages 21-32 as of last completed assessment. Cox proportional hazards regression models were estimated predicting age at first childbirth from history of AD, separately by race/ethnicity, without and with adjustment for sociodemographic characteristics, body mass index, history of other substance involvement, psychopathology, and family and childhood risks. RESULTS: Among EA twins, AD predicted early childbearing through age 17 and delayed childbearing from age 25 onward; in adjusted models, AD was associated with overall delayed childbearing. Among AA twins, reproductive timing and AD were not significantly related in either unadjusted or adjusted models. CONCLUSIONS: Findings for twins of European ancestry are consistent with well-documented links between early alcohol mis/use and teenage parenting as well as delays in childbearing associated with drinking-related reproductive and relationship difficulties. Extension of analyses to other racial/ethnic groups of sufficient sample size remains important.

Acculturation and Health of Korean American Adults.

Increasing cultural diversity in the United States and significant health disparities among immigrant populations make acculturation an important concept to measure in health research. The purpose of this cross-sectional, descriptive study was to examine acculturation and health of Korean American adults. A convenience sample of 517 Korean American adults in a Midwestern city completed a survey in either English or Korean. All four groups of Berry's acculturation model were identified using cluster analysis with Lee's Acculturation Scale. Assimilation, integration, and separation were found in the English survey sample, whereas integration, separation, and marginalization were found in the Korean survey sample. Moreover, the findings revealed that acculturation is a bidimensional process, and the unique nature of samples may determine acculturation groups. Physical health and mental health were significantly related to acculturation in the English survey sample. However, there was not a significant relationship between health and acculturation in the Korean survey sample.

Psychometric evaluations of the efficacy expectations and Outcome Expectations for Exercise Scales in African American women.

This secondary analysis tested the reliability and validity of the Self-Efficacy for Exercise (SEE) and the Outcome Expectations for Exercise (OEE) scales in 126 community dwelling, middle aged African American women. Social Cognitive Theory postulates self-efficacy is behavior age, gender and culture specific. Therefore, it is important to determine ifself-efficacy scales developed and tested in older Caucasian female adults are reliable and valid in middle aged, minority women. Cronbach's alpha and construct validity using hypothesis testing and confirmatory factor analysis supported the reliability and validity of the SEE and OEE scales in community dwelling, middle aged African American women.

Wave of mutilation: the cattle mutilation phenomenon of the 1970s.

During the 1970s many small-scale cattle ranchers across the Midwest reported finding their cattle mutilated. The episode, often dismissed as mass hysteria or sensationalized reporting, demonstrates the growing dissatisfaction of many ranchers concerning government intrusiveness and restrictive policies. These frustrations found a release in response to the mutilation phenomenon during which ranchers vented their anger by taking direct aim at the federal government. The turbulent economic conditions of the period paired with government interference in the cattle industry helped sustain the mutilation phenomenon as ranchers projected their fears and insecurities through the bizarre episode. The hostility ranchers showed toward the federal government during the mutilation scare presaged and helped provide the impetus for events such as the Sagebrush Rebellion. The mutilation phenomenon also underscores the pronounced effects of the libertarian movement of the 1960s that gave rise to the New Right and gained adherents across the West and Midwest.

"We were all trespassers": George Edward Lemmon, Anglo-American cattle ranching, and the Great Sioux Reservation.

With the opening of the Black Hills to white settlement in the mid-1870s, thousands of fortune-seekers made their way into Dakota Territory. George Edward Lemmon, a man later renowned as one of the world's most accomplished cowboys, was among them. During the 1880s his employer, the Sheidley Cattle Company, grazed thousands of cattle in western Dakota Territory, many of them on Sioux Indian land. Indeed, the company owed a great deal of its success to illegal grazing on the Great Sioux Reservation. Opportunists such as Lemmon supported Indian reservations because they could use those lands to make a profit. The interaction between large-scale white ranchers and the Indians of the Great Sioux Reservation provides insight into the development of the range cattle industry in the northern Great Plains and illuminates the motivations that led many ranchers to support, rather than oppose, the reservation system.

Fields of dreams: negotiating an ethanol agenda in the Midwest United States.

Corn ethanol production is central in the United States' agrofuels initiatives. In this paper I discuss corn ethanol production in Iowa, USA and examine several dynamics: farmers' positions in agrofuel supply chains; struggles around the construction and operation of agrofuel refineries; the politics of ethanol production and regulation; and the ecological consequences of increased corn production. I argue that current US agrofuels production and politics reinforce longstanding and unequal political economic relationships in industrial agriculture. I also argue that the politics of US agrofuels, focused on carbon accounting for greenhouse gas reduction and energy security, privilege urban and other actors' social and ecological interests over those of rural places of production.

An unremembered diversity: mixed husbandry and the American grasslands.

The Green Revolution of the 1960s brought about a dramatic rise in global crop yields. But, as most observers acknowledge, this has come at a considerable cost to biodiversity. Plant breeding, synthetic fertilizers, and mechanization steadily narrowed the number of crop varieties commercially available to farmers and promoted fencerow-to-fencerow monocultures. Many historians trace the origins of this style of industrialized agriculture to the last great plow-up of the Great Plains in the 1920s. In the literature, farms in the plains are often described metaphorically as wheat factories, degrading successive landscapes. While in many ways these farms were a departure from earlier forms of husbandry in the American experience, monocultures were quite rare during the early transformation of the plains. Analysis of a large representative sample, based on manuscript agricultural censuses and involving twenty-five townships across the state of Kansas, demonstrates that diverse production reached even the most challenging of plains landscapes.

The intellectual legacy of Mary Neth's work on farm women and rural communities.

Mary Neth's 1995 book, "Preserving the Family Farm: Women, Community, and the Foundations of Agribusiness in the Midwest, 1900-1940," made a major contribution to the analysis of the connections between gender and the political economy that shaped farm women's lives and fueled farmers' resistance to the transformation of rural life wrought by agribusiness. Focusing on the processes of negotiation between women and men in farming families and rural communities, Neth illuminated the relationship between women's work and their power. Tracing the dense networks that connected farm families, she also showed how cooperation in work generated and sustained radical farm movements.

Telling stories: keeping secrets.

This article addresses the reticence of some farm women to share their experiences with historians and how that desire to keep secrets collides with the desire by scholars to tell the stories of these women. It argues that scholars must continue to struggle with the issue of which stories to tell publicly and which to keep private. The author discusses her own experience telling stories about rural women in the 1970s and the need to give voice to the heritage of rural women, especially of groups that have feared revealing their experiences. She offers examples of historians of rural women who have successfully worked with formerly silenced populations and urges historians to continue to tell stories about these lives, to reevaluate what has been already learned, to ask new questions, and to discuss which secrets need to be shared.

"Not to intrude": a Danish perspective on gender and class in nineteenth-century dairying.

This study follows the thread of gender divisions in dairying in Denmark and the American Midwest in the late nineteenth and early twentieth centuries. Gender organization of dairying shifted at this time in diverse European and North American contexts. As agriculture mechanized and production scale increased, access to advanced education and international markets became critical. Women, who had been in the forefront of the development of dairying, ceded their leadership to men as these changes occurred. While some scholars see this shift as a strategic loss for women, this study finds that variables of class, marital status, rural demographics, and alternative occupations mediated the rural women's experience of change. Not all women experienced the change as a loss. The question of which women were invested in dairying is critical to understanding the course of change. Increasingly, middle-class farm women were turning away from the hard work of dairying and investing themselves in new ways in the upward mobility of their family farms. Rural life shaped distinct gender patterns in European and American history, and the rural experience shaped the larger trajectory of women's economic and political evolution, even though few rural women were involved in the organized women's movement.

"Hop to the top with the Iowa Chop": the Iowa Porkettes and cultivating agrarian feminisms in the Midwest, 1964-1992.

Over the course of twenty-eight years, between 1964 and 1991, members of the Iowa Porkettes, the women's auxiliary to the Iowa Pork Producer's Association (IPPA), promoted pork products in order to assert their roles as agricultural producers. For the members of the Porkettes, technological change and the growth of agribusiness provided new opportunities to challenge patriarchal hierarchies in agricultural organizations. Over time, as the overall number of hog farmers declined and the agricultural marketplace increasingly demanded professional expertise, the Porkettes transformed a women's auxiliary into a female-led commodity organization. Initially, members participated in appropriately "feminine" activities including Pork Queen contests, lard-baking contests, consultations with high school home economics instructors, and the distribution of promotional materials. By the late 1970s, however, members began to employ a new rhetoric shaped by their labor on the farm to claim an important stake in the production and marketing of commodities. They took responsibility for large-scale advertising campaigns, managed a growing budget, and became leaders within the IPPA. Their experiences offer insight into broader developments of second wave agrarian feminisms that enabled farm women's organizations to renegotiate gendered divisions of labor, claim new public spaces for women, and demand greater recognition from male agricultural leaders.

Community leaders' perceptions of Hispanic, single, low-income mothers' needs, concerns, social support, and interactions with health care services.

Hispanic, single, low-income mothers are a vulnerable population who are often identified as having difficult transitioning to motherhood and successfully using the U.S. health care system. The purpose of this study was to examine needs, concerns, and social support of Hispanic, single, low-income mothers during the transition to motherhood through the eyes of community leaders serving this population in the U.S. Two focus groups were conducted, and 16 Midwestern community leaders working or volunteering with the Hispanic population expressed their opinions. Two investigators and two graduate nursing students evaluated the data. The process of word and context interpretation was completed using a combination of Tesch (1990) and Creswell (2007) techniques. Data were compared to field notes and debriefing summaries were completed during focus group discussions. Four themes and 12 subthemes evolved from the group discussions. Themes were (a) mothers' social support, (b) interactions with health care providers, (c) barriers in trust, and (d) practical life issues. A conclusion was drawn from these data that these women have difficulty accessing social support and information regarding care of themselves and their newborn infants due to limited social networks and barriers to health care. Nurses are in key positions to offer culturally sensitive social support and identify health care barriers with Hispanic, single, low-income mothers during the transition to motherhood. Further research is needed on interventions that effectively deliver information, lower health care barriers, and meet social support needs of Hispanic, single, low-income mothers and their infants.