Implementing a Teaching Rural Mobile Health Clinic: Challenges and Adaptations.

In 2022, Penn State College of Medicine launched the LION Mobile Clinic, a teaching mobile health clinic offering preventive health services in rural Snow Shoe, Pennsylvania. We outline four challenges the clinic team faced in implementation, along with adaptations made to tailor the model to Snow Shoe's needs and opportunities.

Rural-Urban disparities in self-reported physical/mental multimorbidity: A cross-sectional study of self-reported mental health and physical health among working age adults in the U.S.

Purpose: Self-rated physical health (SRPH) and self-rated mental health (SRMH) are both linked to excess morbidity and premature mortality and can vary across rural and urban contexts. This can be particularly problematic for rural residents who have less access to important health care infrastructure. In this paper, we assess the prevalence of and rural-urban disparities at the intersection of SRPH and SRMH, specifically self-rated physical/mental multimorbidity (SRPMM) overall and across rural-urban contexts. Methods: Using a cross-sectional demographically representative national dataset of over 4000 working age adults in the U.S., we expose rural-urban differences in the prevalence of SRPMM and explore individual-level factors that may explain this disparity. Results: Approximately 15 percent of working age adults reported SRPMM, but rural adults were at higher risk than their urban counterparts. However, this disadvantage disappeared for remote rural working-age adults and was attenuated for metro-adjacent rural working-age adults when we controlled for the fact that rural adults had lower household incomes. Conclusion: Findings reveal a higher risk of SRPMM among rural adults, in part because of lower incomes among this group. This work acts as the foundation for facilitating research on and addressing rural-urban disparities in SRPMM.

Research Note Showing That the Rural Mortality Penalty Varies by Region, Race, and Ethnicity in the United States, 1999-2016.

This research note presents a new perspective on the rural mortality penalty in the United States. While previous work has documented a growing rural mortality penalty, there has been a lack of attention to heterogeneity in trends at the intersection of region, race, and ethnicity. We use age-adjusted mortality rates from the Centers for Disease Control and Prevention to examine the rural mortality penalty by region, race, and ethnicity for 1999-2016 (N = 44,792,050 deaths) and stratify by 2006 National Center for Health Statistics metropolitan-nonmetropolitan classifications. We find substantial variation at the intersection of region, race, and ethnicity, revealing heterogeneity in the rural penalty and-in some cases-a rural mortality advantage. For the Black/African American population, the rural mortality penalty is observed only in the South. On the other hand, for Hispanic/Latino populations, a small but persistent rural mortality penalty is present only in the South and the West. There is a rural mortality penalty in all regions for White and American Indian/Alaska Native populations. However, for the latter, there is substantial variation in the magnitude of the penalty by region of residence. This research documents heterogeneous patterns when the rural mortality penalty is analyzed by region, race, and ethnicity in the United States.

The Built Environment and Social and Emotional Support among Rural Older Adults: The Case for Social Infrastructure and Attention to Ethnoracial Differences.

Social and emotional support (SaES) is essential for older adult mental health and is shaped by individual-level factors and the built environment. However, much of the focus on the built environment, and specifically social infrastructure - the physical places that facilitate social interaction and social tie formation - relies heavily on urban settings or samples with limited diversity. Consequently, there is little understanding if social infrastructure matters for the SaES of older adults in rural America, and across race and ethnicity. Therefore, we use social cohesion as a conceptual lens and the community gerontology framework to determine if availability of social infrastructure is associated with SaES among older adults in rural America and if this relationship varies across race and ethnicity. Using data from 110,850 rural older adults from the Behavioral Risk Factors Surveillance System and data from the National Neighborhood Data Archive, we show that among rural ethnoracial minority older adults, higher densities of social infrastructure are associated with higher SaES. This is not true for rural non-Hispanic White older adults. Results highlight the importance of accounting for both social infrastructure as part of the built environment and heterogeneity across race and ethnicity in studies that examine older adult mental and emotional health.

Can Resilience Buffer the Effects of Loneliness on Mental Distress Among Working-Age Adults in the United States During the COVID-19 Pandemic? A Latent Moderated Structural Modeling Analysis.

BACKGROUND: The profound health consequences of loneliness are well-established. However, less is known about the protective factors which may alleviate the effects of loneliness on mental health especially among working-age adults amidst the COVID-19 pandemic. We draw on the social ecology of resilience and examine whether resilience factors can buffer the effects of loneliness on mental distress. METHODS: Data came from the National Well-being Survey-a national study of a demographically representative sample of U.S. working-age adults (N = 4014). We used (a) structural equation models with latent variables to examine the main effects of loneliness, psychological resilience, and perceived social support on mental distress, and (b) latent moderated structural equations to estimate the latent interaction effects. RESULTS: Results revealed that (a) loneliness was positively associated with mental distress and psychological resilience was negatively related to mental distress, and (b) psychological resilience and perceived social support moderated the strength of the relationship between loneliness and mental distress. CONCLUSIONS: Our study highlights the importance of psychological resilience and perceived social support as two protective factors in the relationship between loneliness and mental distress. Given that loneliness significantly predicts worse mental and physical health and higher mortality, identifying protective factors that might disrupt these connections is vital. As such, public health efforts to strengthen and expand familial and community social support networks and foster psychological resilience are urgently needed to support mental health among working-age adults during additional waves of the pandemic or future similar stressors.

Conceptualizing and Measuring Abatement from the Opioid Epidemic: A Case Study from Pennsylvania.

Policy Points In 2021, four major pharmaceutical manufacturers and distributors reached a proposed settlement agreement with 46 state Attorneys General of $26 billion to address their liabilities in fueling the US opioid epidemic. It raises important questions about abatement conceptualization and measurement for allocating settlement funds among substate entities. We outline the political economy tensions undergirding the settlement and allocation, introduce an abatement conceptual framework, describe how an abatement formula was developed for Pennsylvania to allocate settlement funds, and summarize considerations for future settlement allocation efforts. Documenting the challenges and experiences of this task is essential to inform future efforts.

Rural-Urban Differences in the Associations Between Aging and Disability Services and COVID-19 Vaccination Rates Among Older Adults.

Aging services were poised to play an important role in supporting the COVID-19 vaccination rollout for older adults. In this study, we use ordinary least squares regression models of county-level data (N = 3086) to examine if density of aging and disability services is associated with COVID-19 vaccination rates for older adults in rural and urban areas of the United States. We find that net of compositional characteristics, county-level density of aging and disability services is associated with higher older adult vaccination rates. However, in the rural-urban stratified models, this only remained consistently true for rural counties. Given higher risk of COVID-19 mortality for older adults and larger relative shares of older adults in rural areas, rural counties with low vaccination rates should invest in supporting and/or expanding older adult services to facilitate vaccination.

Perceived mental health impacts of the COVID-19 pandemic: The roles of social support and social engagement for working age adults in the United States.

In this paper we assess if two protective mechanisms for mental health - social support and social engagement - are associated with lower risk of reporting worsening mental health as a result of the pandemic. Using a demographically representative sample of working age adults in the United States (N = 4014) collected in February and March of 2021, we use logistic regression models to predict self-reported worsening mental health as a result of the pandemic using social support - measured as instrumental and emotional support - and social engagement. We use additional stratified models to determine if these relationships are consistent across rural-urban areas. Results indicate that among urban working age adults, emotional support, high levels of instrumental support, and some types of social engagement were associated with significantly lower risk of worsening mental health. However, among rural working age adults, only emotional support and high levels of instrumental support were significantly associated with lower odds of worsening mental health. Findings suggest that while emotional support may be effective for working age adults in lowering risk of worsening mental health from the pandemic, social engagement may not be for rural residents. The results support use of mental health promotion and prevention approaches that bolster emotional support through familial and local social networks, and raises caution about the efficacy of social engagement approaches in rural contexts.

Self-Rated Physical Health Among Working-Aged Adults Along the Rural-Urban Continuum - United States, 2021.

Poor self-rated physical health is strongly associated with morbidity and premature mortality (1,2). Studies that are now a decade old report worse self-rated health among rural than among urban residents (3,4). Whether the rural disadvantage persists in 2021 is uncertain and the contributing factors to contemporary rural-urban variations in self-rated health are not known. Rural America is diverse by population size and adjacency to metropolitan areas, and rural populations vary demographically and socioeconomically. This analysis used data from the National Well-being Survey (NWS), a national sample of approximately 4,000 U.S. working-aged adults conducted during February and March 2021 to examine differences in self-rated physical health among residents of large urban; medium/small urban; metro-adjacent rural; and remote rural counties. Residents of medium/small urban, metro-adjacent rural, and remote rural counties had significantly higher probabilities of reporting fair/poor self-rated physical health than their large urban county peers. There were no significant differences by sex or race/ethnicity in self-rated physical health. Individual-level socioeconomic resources (including higher educational attainment, higher household income, and higher probability of employment) contributed to the advantage among residents of large urban counties. Although there is no single solution to reducing rural-urban health disparities, these findings suggest that reducing socioeconomic disparities is essential.

Sociospatial Disparities in "Third Place" Availability in the United States.

Tertiary to home and work, "third places" serve as opportunity structures that transmit information and facilitate social capital and upward mobility. However, third places may be inequitably distributed, thereby exacerbating disparities in social capital and mobility. The authors use tract-level data from the National Neighborhood Data Archive to examine the distribution of third places across the United States. There were significant disparities in the availability of third places. Higher poverty rates were associated with fewer third places. Tracts with the smallest shares of Black and Hispanic populations had comparatively more third places. However, this racial disadvantage was not linear, suggesting potential buffering effects in places with the largest shares of Black and Hispanic populations. There was also a rural disadvantage, except in the most isolated rural tracts. This study demonstrates the value of conceptualizing and measuring third places to understand sociospatial disparities in the availability of these understudied opportunity structures.

Socio-Spatial Disparities in County-Level Availability of Aging and Disability Services Organizations.

Aging and disability services are essential for supporting older adults in living independently in their homes and communities as they age. Applying theoretical perspectives of community gerontology and spatial inequality, we use county-level data (N=3142) from the National Neighborhood Data Archive (NaNDA) and the American Community Survey to explore if and how availability of aging and disability services organizations varies across the rural-urban continuum and across compositional characteristics of counties. Results show that rural counties are significantly more likely to be aging and disability services deserts. Stratified models show that poverty rates and relative shares of non-Hispanic Blacks are positively associated with greater odds of aging and disability services deserts across rural and urban counties, but divergent findings appear for county-level shares of Hispanics. These findings are discussed as well as implications for research, policy, and practice on equitable access to aging and disability services.

Barriers for Implementing the Hub and Spoke Model to Expand Medication for Opioid Use Disorder: A Case Study of Montana.

PURPOSE: Access to medication for opioid use disorder (MOUD) varies across the rural-urban continuum. The Hub & Spoke Model (H&S) emerged to address these gaps in service whereby hubs with staff expertise in MOUD support delivery of specialized care to a network of spoke locations, often located in rural communities with workforce shortages. This paper presents a case study of efforts to implement the hub and spoke model in a frontier and rural (FAR) state: Montana. METHODS: The primary data are structured interviews with 65 MOUD program staff in hub and spoke locations within Montana. Both inductive and deductive coding were used to analyze the transcripts. FINDINGS: Using the H&S structure to expand access to MOUD in Montana led to mixed results. There were consistent themes identified in the interviews about the reasons why hubs struggled to successfully recruit spokes, including (1) geographic barriers, (2) a lack of interest among medical providers, (3) fears about excessive demand, (4) concerns about the financial viability of the model, and (5) a preference for informal technical assistance rather than a formal H&S relationship. In addition to these 5 themes, efforts to implement H&S across different medical systems were unsuccessful, whereas the H&S model worked more effectively when H&S locations were within the same organization. CONCLUSION: This case study identified limits to the H&S model utility in supporting states' abilities to expand access to MOUD treatment and offers suggestions for adapting it to accommodate variation across divergent rural contexts. We conclude with recommendations for strategies that may assist in expansion of MOUD in rural communities that are like those found in Montana.

Disparities in individual health behaviors between medicaid expanding and non-expanding states in the U.S.

Following the roll out of the Affordable Care Act, a significant amount of research has focused on health insurance coverage disadvantages experienced by those in states that chose not to expand Medicaid. This line of research has been used as a way to conceptualize potential disparities in future population health outcomes between states that did and did not expand Medicaid. While health insurance is certainly associated with health outcomes, health behaviors are equally, if not more, important. Therefore, to understand potential future population health outcomes - or lack thereof - this paper examines whether adults in states that did not expand Medicaid are also more likely to engage in health damaging behaviors (i.e. smoking, heavy drinking, physical inactivity, and overweight and obesity) than adults in states that expanded Medicaid. I find that those in states that did not expand Medicaid are more likely to be overweight and obese but are less likely to drink heavily compared to adults in states that did expand Medicaid. In part, higher rates of demographic and socioeconomic disadvantage explain higher rates of health damaging behaviors in states that did not expand Medicaid. This paper raises concerns about added long term consequences for population health and growing health disparities between states that did and did not expand Medicaid. Policy and practice implications of these findings are discussed.

Differences in Human Papillomavirus Vaccination Among Adolescent Girls in Metropolitan Versus Non-metropolitan Areas: Considering the Moderating Roles of Maternal Socioeconomic Status and Health Care Access.

OBJECTIVES: This study is among the first to examine metropolitan status differences in human papillomavirus (HPV) vaccine initiation and completion among United States adolescent girls and is unique in its focus on how maternal socioeconomic status and health care access moderate metropolitan status differences in HPV vaccination. METHODS: Using cross-sectional data from 3573 girls aged 12-17 in the U.S. from the 2008-2010 Behavioral Risk Factor Surveillance System, we estimate main and interaction effects from binary logistic regression models to identify subgroups of girls for which there are metropolitan versus non-metropolitan differences in HPV vaccination. RESULTS: Overall 34 % of girls initiated vaccination, and 19 % completed all three shots. On average, there were no metropolitan status differences in vaccination odds. However, there were important subgroup differences. Among low-income girls and girls whose mothers did not complete high school, those in non-metropolitan areas had significantly higher probability of vaccine initiation than those in metropolitan areas. Among high-income girls and girls whose mothers completed college, those in metropolitan areas had significantly higher odds of vaccine initiation than those in non-metropolitan areas. Moreover, among girls whose mothers experienced a medical cost barrier, non-metropolitan girls were less likely to initiate vaccination compared to metropolitan girls. CONCLUSIONS: Mothers remain essential targets for public health efforts to increase HPV vaccination and combat cervical cancer. Public health experts who study barriers to HPV vaccination and physicians who come into contact with mothers should be aware of group-specific barriers to vaccination and employ more tailored efforts to increase vaccination.