Rural-urban differences in meeting of physical activity recommendations by sun exposure and protection behaviors in the United States.

OBJECTIVE: To examine associations between sun protection behaviors and physical activity (PA) by rural and urban residence in the United States. METHODS: We analyzed data from the National Health and Nutrition Examination Survey (2013-2018), restricting to participants ages 20-59 with sun behavior data. Sunburns, sun exposure, and sun protection measures were dichotomized (yes/no): ≥1 sunburn in the past year, 2+ hour outside during workdays or non-workdays, and never/rarely/sometimes using sunscreen, wearing long sleeves, and staying in the shade. Meeting PA recommendations (yes/no) was defined as ≥150 min of vigorous/moderate or ≥ 75 min vigorous PA per week. Associations between sun behaviors and PA were analyzed using logistic regression models, which accounted for survey-weights and potential confounders, and stratified by rural-urban status. RESULTS: Rural and urban individuals meeting PA recommendations had greater odds of spending 2+ hour outside during workdays (OR: 2.26 [1.88, 2.74] and 3.95 [2.72, 5.73]) and non-workdays (OR: 2.06 [1.78, 2.38] and 3.33 [2.47, 4.46]). Among urban residents, odds of staying in the shade were lower among those who met PA recommendations (OR: 0.78 [0.66, 0.92]). We did not observe differences in sunburns or other sun behaviors by PA status, regardless of rurality. CONCLUSIONS: Meeting PA recommendations was associated with greater sun exposure in both rural and urban populations. Additional exercise location (indoors/outside) data is needed to inform PA and skin cancer prevention interventions to reduce unintended increases in sun exposure and reductions in PA, respectively, especially among rural populations.

Rural/urban differences in mental health and social well-being among older US adults in the early months of the COVID-19 pandemic.

OBJECTIVES: This study seeks to identify differences in mental health and social well-being during the early months of the COVID-19 pandemic among older adults by rural/urban location. METHODS: We use data from the COVID-19 Coping Study, a nation-wide online study of U.S. adults aged 55 and older (n = 6,873) fielded during April-May, 2020. We investigated rural/urban differences in mental health (depressive symptoms and anxiety symptoms) and social well-being (loneliness and social isolation); concern about COVID-19; and types of social participation (e.g. phone/video calls, visits). We also used multivariable logistic regression models to assess the relationship of rurality with mental health, adjusting for socio-demographic correlates, COVID-19 history, and COVID-19 concern. RESULTS: We found similar prevalence of mental health and social well-being outcomes for rural and urban respondents. Rural respondents reported lower concern about COVID-19 and more frequent use of social media than urban respondents. CONCLUSION: Mental health and social well-being did not differ by rural/urban location in the early months of the COVID-19 pandemic. However, rural residents reported less concern about COVID-19 and more use of social media, potentially leading to greater risk of illness from the pandemic in later months.

"Going Back in the Closet": Addressing Discrimination Against Sexual and Gender Minority Residents in Long-Term Services and Supports by Providing Culturally Responsive Care.

Sexual and gender minority (SGM) older adults face discrimination in long-term services and supports (LTSS). Yet, SGM older adults use LTSS disproportionately higher relative to their non-SGM counterparts. The discrimination is compounded by existing disparities, resulting in worse health outcomes and well-being for SGM older adults. Guided by socioecological model, we posit that training LTSS staff in SGM responsive care and implementing SGM anti-discrimination policies will be needed to improve care. Considering accessibility and turnover challenges, training should be online, interactive, and easily accessible. Studies that assess interventions for SGM responsive care are needed to guide policy and practice.

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.

Racial and Ethnic Differences in Self-Rated Health Among Rural Residents.

This study examines racial and ethnic differences in self-rated health among rural residents and whether these differences can be explained by socio-demographic characteristics. We used data from the 2011-2017 National Health Interview Survey to assess differences in self-rated health by race and ethnicity among rural residents (living in non-metropolitan counties; n = 46,883). We used logistic regression analyses to estimate the odds of reporting fair/poor health after adjusting for individual socio-demographic characteristics. Non-Hispanic Black and American Indian rural residents reported worse self-rated health than their non-Hispanic White counterparts (25.8% and 20.8% reporting fair/poor health, respectively, vs. 14.8%; p < 0.001). After adjusting for socio-demographic characteristics, disparities remained for non-Hispanic Black rural residents (Adjusted Odds Ratio = 1.55; 95% CI 1.36, 1.76). This study suggests more attention is required to address inequities among rural people and to develop policies to address structural racism and improve the health of all rural residents.

Role of Health Literacy in Health-Related Information-Seeking Behavior Online: Cross-sectional Study.

BACKGROUND: The internet has emerged as a main venue of health information delivery and health-related activities. However, few studies have examined how health literacy determines online health-related behavior. OBJECTIVE: The aim of this study was to investigate the current level of health-related information-seeking using the internet and how health literacy, access to technology, and sociodemographic characteristics impact health-related information-seeking behavior. METHODS: We conducted a cross-sectional study through a survey with Minnesotan adults (N=614) to examine their health literacy, access to technology, and health-related information-seeking internet use. We used multivariate regression analysis to assess the relationship between health-related information-seeking on the internet and health literacy and access to technology, controlling for sociodemographic characteristics. RESULTS: Better health literacy (ß=.35, SE 0.12) and greater access to technological devices (eg, mobile phone and computer or tablet PC; ß=.06, SE 0.19) were both associated with more health-related information-seeking behavior on the internet after adjusting for all other sociodemographic characteristics. Possession of a graduate degree (ß=.28, SE 0.07), female gender (ß=.15, SE 0.05), poor health (ß=.22, SE 0.06), participation in social groups (ß=.13, SE 0.05), and having an annual health exam (ß=.35, SE 0.12) were all associated with online health-related information-seeking. CONCLUSIONS: Our findings indicate that access to online health-related information is not uniformly distributed throughout the population, which may exacerbate disparities in health and health care. Research, policy, and practice attention are needed to address the disparities in access to health information as well as to ensure the quality of the information and improve health literacy.

Characteristics of US Rural Hospitals by Obstetric Service Availability, 2017.

Objectives. To describe characteristics of rural hospitals in the United States by whether they provide labor and delivery (obstetric) care for pregnant patients.Methods. We used the 2017 American Hospital Association Annual Survey to identify rural hospitals and describe their characteristics based on the lack or provision of obstetric services.Results. Among the 2019 rural hospitals in the United States, 51% (n = 1032) of rural hospitals did not provide obstetric care. These hospitals were more often located in rural noncore counties (counties with no town of more than 10 000 residents). Rural hospitals without obstetrics also had lower average daily censuses, were more likely to be government owned or for profit compared with nonprofit ownership, and were more likely to not have an emergency department compared with hospitals providing obstetric care (P for all comparisons < .001).Conclusions. Rural US hospitals that do not provide obstetric care are located in more sparsely populated rural locations and are smaller than hospitals providing obstetric care.Public Health Implications. Understanding the characteristics of rural hospitals by lack or provision of obstetric services is important to clinical and policy efforts to ensure safe maternity care for rural residents.

The Unique Impact of COVID-19 on Older Adults in Rural Areas.

Older adults in rural areas of the U.S. face unique risks related to COVID-19. Rural areas are older, on average, than urban areas, and have more underlying health conditions and fewer economic resources. Rural health care is more limited, as is access to technology and online connectivity. Altogether, this puts rural older adults at risk of not only the virus, but of not being able to meet their health care, social, and basic needs. Rural/urban inequities, combined with within-rural inequities in health, health care, and financial resources cause particular challenges to health and well-being from COVID-19 for some older adults.

Differences by Sexual Orientation in Perceptions of Neighborhood Cohesion: Implications for Health.

A large body of research documents the relationship between health and place, including the positive association between neighborhood cohesion and health. However, very little research has examined neighborhood cohesion by sexual orientation. This paper addresses that gap by examining differences in perceived neighborhood cohesion by sexual orientation. We use data from the 2016 National Health Interview Survey (n = 28,164 respondents aged 18 years and older) to examine bivariate differences by sexual orientation in four measures of neighborhood cohesion. We then use ordered logistic regression models to assess the relationship between sexual orientation and a scaled measure of neighborhood cohesion, adjusting for socio-demographic characteristics, living arrangements, health status, region, and neighborhood tenure. We find that lesbian, gay, and bisexual (LGB) adults are less likely to say that they live in a close-knit neighborhood (54.6 vs. 65.6%, p < 0.001), they can count on their neighbors (74.7 vs. 83.1%, p < 0.001), they trust their neighbors (75.5 vs. 83.7%, p < 0.001), or people in their neighborhood help each other out (72.9 vs. 83.1%, p < 0.001), compared to heterosexual adults. Even after controlling for socio-demographic factors, neighborhood cohesion scores are lower for LGB adults compared to heterosexual adults (odds ratio of better perceived neighborhood cohesion for sexual minorities: 0.70, p < 0.001). Overall, LGB adults report worse neighborhood cohesion across multiple measures, even after adjusting for individual characteristics and neighborhood tenure. Because living in a cohesive neighborhood is associated with better health outcomes, future research, community-level initiatives, and public policy efforts should focus on creating welcoming neighborhood environments for sexual minorities.

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States.

Importance: Hospital-based obstetric services have decreased in rural US counties, but whether this has been associated with changes in birth location and outcomes is unknown. Objective: To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties. Design, Setting, and Participants: A retrospective cohort study, using county-level regression models in an annual interrupted time series approach. Births occurring from 2004 to 2014 in rural US counties were identified using birth certificates linked to American Hospital Association Annual Surveys. Participants included 4 941 387 births in all 1086 rural counties with hospital-based obstetric services in 2004. Exposures: Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas. Main Outcomes and Measures: Primary outcomes were county rates of (1) out-of-hospital births; (2) births in hospitals without obstetric units; and (3) preterm births (<37 weeks' gestation). Results: Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services. Of the 4 941 387 births studied, the mean (SD) maternal age was 26.2 (5.8) years. A mean (SD) of 75.9% (23.2%) of women who gave birth were non-Hispanic white, and 49.7% (15.6%) were college graduates. Rural counties not adjacent to urban areas that lost hospital-based obstetric services had significant increases in out-of-hospital births (0.70 percentage points [95% CI, 0.30 to 1.10]); births in a hospital without an obstetric unit (3.06 percentage points [95% CI, 2.66 to 3.46]); and preterm births (0.67 percentage points [95% CI, 0.02 to 1.33]), in the year after loss of services, compared with those with continual obstetric services. Rural counties adjacent to urban areas that lost hospital-based obstetric services also had significant increases in births in a hospital without obstetric services (1.80 percentage points [95% CI, 1.55 to 2.05]) in the year after loss of services, compared with those with continual obstetric services, and this was followed by a decreasing trend (-0.19 percentage points per year [95% CI, -0.25 to -0.14]). Conclusions and Relevance: In rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.

Beyond Clinical Complexity: Nonmedical Barriers to Nursing Home Care for Rural Residents.

We conducted a qualitative content analysis of barriers to nursing home admission for rural residents. Data came from semi-structured interviews with 23 rural hospital discharge planners across five states (Georgia, Idaho, Minnesota, Pennsylvania, and Wisconsin). From those, we identified four themes around nonmedical barriers to rural nursing home placement with particular salience in rural areas: financial issues, transportation, nursing home availability and infrastructure, and timeliness. We also identified policy and programmatic interventions across four themes: loosen bureaucratic requirements, improve communication between facilities, increase rural long-term care capacity, and address underlying social determinants of health.

Rural-Urban Differences in Medicare Quality Outcomes and the Impact of Risk Adjustment.

BACKGROUND: There has been considerable debate in recent years about whether, and how, to risk-adjust quality measures for sociodemographic characteristics. However, geographic location, especially rurality, has been largely absent from the discussion. OBJECTIVE: To examine differences by rurality in quality outcomes, and the impact of adjustment for individual and community-level sociodemographic characteristics on quality outcomes. DATA SOURCES: The 2012 Medicare Current Beneficiary Survey, Access to Care module, combined with the 2012 County Health Rankings. All data used were publicly available, secondary data. We merged the 2012 Medicare Current Beneficiary Survey data with the 2012 County Health Rankings data using county of residence. RESEARCH DESIGN: We compared 6 unadjusted quality of care measures for Medicare beneficiaries (satisfaction with care, blood pressure checked, cholesterol checked, flu shot receipt, change in health status, and all-cause annual readmission) by rurality (rural noncore, micropolitan, and metropolitan). We then ran nested multivariable logistic regression models to assess the impact of adjusting for community and individual-level sociodemographic characteristics to determine whether these mediate the rurality difference in quality of care. RESULTS: The relationship between rurality and change in health status was mediated by the inclusion of community-level characteristics; however, adjusting for community and individual-level characteristics caused differences by rurality to emerge in 2 of the measures: blood pressure checked and cholesterol checked. For all quality scores, model fit improved after adding community and individual characteristics. CONCLUSIONS: Quality is multifaceted and is impacted by individual and community-level socio-demographic characteristics, as well as by geographic location. Current debates about risk-adjustment procedures should take rurality into account.

Barriers to Care Among Transgender and Gender Nonconforming Adults.

Policy Points: Transgender and gender nonconforming (GNC) adults may experience barriers to care for a variety of reasons, including discrimination and lack of awareness by providers in health care settings. In our analysis of a large, population-based sample, we found transgender and GNC adults were more likely to be uninsured and have unmet health care needs, and were less likely to have routine care, compared to cisgender (nontransgender) women. Our findings varied by gender identity. More research is needed on transgender and GNC populations, including on how public policy and provider awareness affects health care access and health outcomes differentially by gender identity. CONTEXT: Very little population-based research has examined health and access to care among transgender populations. This study compared barriers to care between cisgender, transgender, and gender nonconforming (GNC) adults using data from a large, multistate sample. METHODS: We used data from the 2014-2015 Behavioral Risk Factor Surveillance System to estimate the prevalence of having no health insurance, unmet medical care needs due to cost, no routine checkup, and no usual source of care for cisgender women (n = 183,370), cisgender men (n = 131,080), transgender women (n = 724), transgender men (n = 449), and GNC adults (n = 270). Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for each barrier to care while adjusting for sociodemographic characteristics. FINDINGS: Transgender and GNC adults were more likely to be nonwhite, sexual minority, and socioeconomically disadvantaged compared to cisgender adults. After controlling for sociodemographic characteristics, transgender women were more likely to have no health insurance (OR = 1.60; 95% CI = 1.07-2.40) compared to cisgender women; transgender men were more likely to have no health insurance (OR = 2.02; 95% CI = 1.25-3.25) and no usual source of care (OR = 1.84; 95% CI = 1.18-2.88); and GNC adults were more likely to have unmet medical care needs due to cost (OR = 1.93; 95% CI = 1.02-3.67) and no routine checkup in the prior year (OR = 2.41; 95% CI = 1.41-4.12). CONCLUSIONS: Transgender and GNC adults face barriers to health care that may be due to a variety of reasons, including discrimination in health care, health insurance policies, employment, and public policy or lack of awareness among health care providers on transgender-related health issues.

Health Disparities by Sexual Orientation: Results and Implications from the Behavioral Risk Factor Surveillance System.

Until recently, population-based data for monitoring sexual minority health have been limited, making it difficult to document and address disparities by sexual orientation. The primary objective of this study was to examine differences by sexual orientation in an array of health outcomes and health risk factors using one of the nation's largest health surveys. Data for this study came from 8290 adults who identified as lesbian, gay, or bisexual (LGB) and 300,256 adults who identified as heterosexual in the 2014-2015 Behavioral Risk Factor Surveillance System (BRFSS). Logistic regression models were used to compare physical and mental health outcomes, health condition diagnoses, and health risk factors by sexual orientation, controlling for demographic and socioeconomic status. Controlling for sociodemographic characteristics, gay and bisexual men reported higher odds of frequent mental distress [odds ratio (OR) 1.71, P = 0.001; OR 2.33, P < 0.001] and depression (OR 2.91, P < 0.001; OR 2.41, P < 0.001), compared with heterosexual men. Lesbian and bisexual women had higher odds of frequent mental distress (OR 1.53, P < 0.001; OR 2.08, P < 0.001) and depression (OR 1.93, P < 0.01; OR 3.15, P < 0.001), compared to heterosexual women. Sexual minorities also faced higher odds of poor physical health, activity limitations, chronic conditions, obesity, smoking, and binge drinking, although these risks differed by sexual orientation and gender. This study adds to the mounting evidence of health disparities by sexual orientation. Community health practitioners and policymakers should continue to collect data on sexual orientation in order to identify and address root causes of sexual orientation-based disparities, particularly at the community-level.

Availability of Child Care in Rural Communities: Implications for Workforce Recruitment and Retention.

The objective of this study was to identify differences in child care availability by rural-urban location for all counties in Wisconsin, and describe implications for recruitment and retention of health care workforce. We used data on licensed child care slots for young children (age <5), socio-demographic characteristics, women's and men's labor force participation, and household structure for all counties in Wisconsin in 2013 (n = 72). Data came from KIDS COUNT, County Health Rankings, and the American Community Survey. We used t tests to analyze bivariate differences in child care availability and community characteristics by metropolitan, micropolitan, and non-core rural location. We then used ordinary least squares regression to analyze the relationship between geographic location and child care slots, adjusting for labor force participation and household structure. Rural counties had significantly fewer licensed child care slots per child than metropolitan and micropolitan counties. These counties also had, on average, higher rates of poverty and higher unemployment than micropolitan and metropolitan counties. The association between geographic location and child care availability remained, even after adjusting for household structure and labor force participation. The number of hours men worked and the percentage of men not working were both negatively associated with available child care slots, whereas there was not a significant relationship between women's labor force participation and child care availability. Rural areas face health care workforce shortages. Recruitment strategies to overcome shortages must move beyond individual-level incentives to focus on community context and family support, including availability of child care in rural counties.

Rural Implications of Expanded Birth Volume Threshold for Reporting Perinatal Care Measures.

BACKGROUND: In 2016 the minimum annual birth volume threshold for required reporting of the Joint Commission Perinatal Care measures by accredited hospitals decreased from 1,100 to 300 births. METHODS: Publicly available Joint Commission Quality Check data from April 2014 to March 2015 for three Perinatal Care measures were linked to Medicare Provider of Services and American Hospital Association Annual Survey data. For each measure, hospital-level reporting and performance among accredited hospitals providing obstetric care were compared using Fisher's exact tests. RESULTS: Sixty-seven percent of the 2,396 accredited hospitals with obstetric services reported at least one eligible patient for two of the four reported Perinatal Care measures: Elective delivery and exclusive breast milk feeding. Fewer hospitals (35.0%) had data on the antenatal steroids measure; many hospitals may not have any eligible patients for this measure. Hospitals with higher birth volume, those in urban counties, and those with private, nonprofit ownership or system affiliation were more likely to report the perinatal measures (p < 0.001). Across states, reporting rates varied considerably. By hospital volume, performance varied more on the antenatal steroids measure (78.0% to 91.5%) than on the breast milk feeding measure (48.4% to 49.5%) and the elective delivery measure (2.5% to 3.0%). CONCLUSIONS: Expansion of the minimum birth volume threshold nearly doubles the number of accredited hospitals required to report the Perinatal Care measures to The Joint Commission. However, 485 accredited hospitals with obstetric services that are either critical access hospitals or have fewer than 300 births annually are still exempt from reporting. Although many rural hospitals remain exempt from reporting requirements, the measures offer an opportunity for both rural and urban hospitals to assess and improve care.

Rural-Urban Differences in Satisfaction with Medicare Part D: Implications for Policy.

Rural residents are more likely to be enrolled in traditional fee-for-service Part D Medicare prescription drug plans, and they face particular challenges in accessing pharmaceutical care. This study examines rural/urban differences in satisfaction with Medicare Part D coverage. Using data from the 2012 Medicare Current Beneficiary Survey (N = 3,107 beneficiaries aged 65 and older), we find that rural residents have significantly lower satisfaction with Part D coverage but that regional variation in satisfaction is largely explained by differences in health services use and type of Part D plan (stand-alone versus Medicare Advantage). We conclude by suggesting a multifaceted approach to improving satisfaction with Part D for rural residents.