Patient Attitudes and Perceived Barriers Toward Mental Health Treatment Options in a Rural Student-Run Clinic.

Background While the prevalence of mental health conditions is similar in rural areas and non-rural areas, access to mental health care is more limited in rural areas. Patient attitudes toward specific mental health treatment options in rural populations have been understudied. Some previous studies indicate potential positive outcomes using osteopathic manipulative treatment (OMT) as an adjunct for mental health care. Physicians using OMT are more heavily represented in rural areas. Hence, understanding the mental health treatment needs and option preferences of the rural could inform policies that increase underserved population's access to various mental health treatment modalities including OMT. This study aims to characterize patient attitudes toward, beliefs regarding, and perceived barriers to treatment options for mental health treatment, access, and care in a rural, underserved clinical setting. Methods Adult patients attending a single outpatient rural clinic over a four-month period in 2022 were screened for participation. The survey consisted of Likert scale graded questions about mental health treatment options, access, knowledge, and perceived barriers including qualitative questions about OMTs. Versions of the survey were created in English and Spanish languages. Results Out of 46 respondents, 25 were English-speaking and 21 were Spanish-speaking. The most popular mental health treatments by respondents were indicated as therapy, spiritual guidance, and modifying diet and exercise. Considering barriers to care, 61% of respondents indicated cost of treatment as a logistical barrier. Finally, 80.5% of respondents did not have a good understanding of OMT. Conclusions The knowledge and understanding of patients' perceived attitudes and barriers toward mental health care, inclusive of OMT, can provide insight to clinicians to improve patient outcomes and guide efforts in overcoming barriers to increase and expand mental health treatment availability and utilization by patients.

Advanced Endoscopic Evaluation of Gastroesophageal Reflux Disease in Morbidly Obese Patients in a Rural Setting.

INTRODUCTION: Obesity is a known risk factor for gastroesophageal reflux disease (GERD). Morbidly obese patients in rural areas are usually referred to the local surgeon for endoscopic evaluation. This situation poses significant challenges given the increased risk for perioperative complications due to anatomical and metabolic factors. This study aims to evaluate the safety of performing GERD diagnostic workup studies in a rural setting. METHODS: Institutional review board approval was obtained for a retrospective chart review of patients who presented with GERD symptoms to a rural antireflux clinic between August 2015 and October 2020. Patients were included if their body mass index (BMI) was over 35 with comorbidities or over 40 kg/m2 who underwent upper gastrointestinal endoscopy with or without concomitant placement of wireless pH probe and/or functional luminal imaging probe. RESULTS: A total of 117 patients met the inclusion criteria. There were 94 (80.3%) females and 23(19.7%) males. The average age was 56.0 ± 13.4 years. The average BMI was 40.4 (35-66.4). Proton pump inhibitor use was noted in 97/117 (82.9%) with an average duration of 12.0 ± 9.2 years. The average GERD-Health Related Quality of Life, Reflux Symptom Index and GERD Symptom Score (GERSS) were 29.8 ± 20, 24.5 ± 14.2 and 21.3 ± 15.4 respectively. There were no procedural complications. All the endoscopic examinations were successfully completed and patients were discharged. CONCLUSION: Performing diagnostic studies for GERD for morbidly obese patients in critical access hospitals is safe. Patient selection, proper training and adequate preparation are critical prerequisites for good outcomes.

Red Blood Cell Metabolism in Pyruvate Kinase Deficient Patients.

Background: Pyruvate kinase deficiency (PKD) is the most frequent congenital enzymatic defect of glycolysis, and one of the most common causes of hereditary non spherocytic hemolytic anemia. Therapeutic interventions are limited, in part because of the incomplete understanding of the molecular mechanisms that compensate for the metabolic defect. Methods: Mass spectrometry-based metabolomics analyses were performed on red blood cells (RBCs) from healthy controls (n=10) and PKD patients (n=5). Results: In PKD patients, decreases in late glycolysis were accompanied by accumulation of pentose phosphate pathway (PPP) metabolites, as a function of oxidant stress to purines (increased breakdown and deamination). Markers of oxidant stress included increased levels of sulfur-containing compounds (methionine and taurine), polyamines (spermidine and spermine). Markers of hypoxia such as succinate, sphingosine 1-phosphate (S1P), and hypoxanthine were all elevated in PKD subjects. Membrane lipid oxidation and remodeling was observed in RBCs from PKD patients, as determined by increases in the levels of free (poly-/highly-unsaturated) fatty acids and acyl-carnitines. Conclusion: In conclusion, in the present study, we provide the first overview of RBC metabolism in patients with PKD. Though limited in scope, the study addresses the need for basic science to investigate pathologies targeting underrepresented minorities (Amish population in this study), with the ultimate goal to target treatments to health disparities.

The Burden of Obesity in the Rural Adult Population of America.

There is an epidemic of obesity in adults in rural America. It is estimated that about 19% of the population resides in rural areas, which encompasses 97% of America's total landmass. Although rural America makes up a fraction of America's total population, it has been estimated that the prevalence of obesity is approximately 6.2 times higher than in urban America. This illustrates an apparent disparity that exists between the rural population and urban populations that needs to be examined. The prevalence of obesity, especially in rural America, is a growing concern in the medical community in recent years. Obesity has been identified as a significant risk factor for cardiovascular disease, cancer, and type 2 diabetes mellitus, which are leading causes of morbidity and mortality in the US. To better understand the disparity in the prevalence of adult obesity between rural and urban America, researchers have identified risk factors that are associated with the high incidence and prevalence of obesity in the rural American adult population. Low income and lack of physical activity have been identified as factors that predispose rural Americans to increased risk of obesity, arguing that low-income Americans may not have access to the resources available to assist them in weight reduction. With rural Americans being at an income disadvantage, it creates a risk for obesity, which further predisposes them to chronic diseases such as hypertension, obstructive sleep apnea (OSA), diabetes, and coronary artery disease. As obesity continues to rise among the American population, the burden on the rural population is incredibly evident. Despite ongoing efforts by the US government and strategies implemented by the Common Community Measures for Obesity Prevention, there is still much to be done to tackle the epidemic. With an existing strategy in place, such as the 12 Common Community Measures for Obesity Prevention (COCOMO) strategies to fight obesity with physical activity, Americans are a step closer to conquering this epidemic. However, until other disparities such as income are addressed, rural Americans may continue to be severely impacted by the rising incidence of obesity and subsequent higher mortality rates from associated diseases.

Patients' Attitudes and Sources of Information on Coronavirus Disease 2019 in Rural Michigan.

Background This study investigated patients' attitudes about severe acute respiratory syndrome coronavirus 2 in rural Michigan. Despite increasing cases in rural communities across America, surveys have revealed that residents may feel less threatened by the virus compared to their urban counterparts. This difference in attitude and information appraisal can negatively affect rural health by discouraging coronavirus disease (COVID-19) preventative behaviors. Understanding social influences that contribute to the formation of opinions about the pandemic can help public health officials and clinicians better address rural health. Methodology This cross-sectional study surveyed 299 participants from three primary care clinics in Shiawassee County of Michigan during a seven-week interval. Statistical analysis, primarily through SAS version 9.4 (SAS Institute Inc., Cary, NC, USA), included descriptive statistics, multiple linear regression models, paired t-tests, and correlation coefficients. A p-value less than or equal to 0.05 was considered significant. Results Patients believed the risk COVID-19 posed to their family was significantly higher than the risk it posed to themselves (p < 0.001). Patients who reported that they would follow their provider's advice for treatment of a non-COVID-19 medical illness were found to be more likely to follow a provider's advice on COVID-19 (p < 0.001). However, patients overall were more agreeable with following provider advice for non-COVID-19 medical illnesses than they were for COVID-19 (p < 0.001). Conclusions As patients were more agreeable with following medical advice on chronic conditions than COVID-19, there may be extrinsic factors influencing patient views of COVID-19. Polarization of COVID-19 in the media has heavily influenced attitudes toward the virus in America. Initiatives to provide reliable patient education is key to encouraging constructive discussions and a healthy rural community. In a strong patient-provider relationship, primary care providers can share and encourage appropriate healthy behaviors regarding COVID-19, which have a direct impact on community health.

A spectrum of (Dis)Belief: Coronavirus frames in a rural midwestern town in the United States.

Community responses to the SARS-CoV-2, or "coronavirus" outbreaks of 2020 reveal a great deal about society. In the absence of government mandates, debates over issues such as mask mandates and social distancing activated conflicting moral beliefs, dividing communities. Policy scholars argue that such controversies represent fundamental frame conflicts, which arise from incommensurable worldviews, such as contested notions of "liberty" versus "equity". This article investigates frames people constructed to make sense of coronavirus and how this affected social behavior in 2020. We conducted an interpretive framing analysis using ethnographic data from a predominately white, conservative, and rural midwestern tourist town in the United States from June to August 2020. We collected semi-structured interviews with 87 community members, observed meetings, events, and daily life. We identified four frames that individuals constructed to make sense of coronavirus: Concern, Crisis, Constraint, and Conspiracy. Concern frames illustrated how some individuals are uniquely affected and thus protect themselves. Crisis frames recognized coronavirus as a pervasive and profound threat requiring unprecedented action. Constraint frames emphasized the coronavirus response as a threat to financial stability and personal growth that should be resisted. Conspiracy frames denied its biological basis and did not compel action. These four conflicting frames demonstrate how social fragmentation, based on conflicting values, led to an incomplete pandemic response in the absence of government mandates at the national, state, and local levels in rural America. These findings provide a social rationale for public health mandates, such as masking, school/business closures, and social distancing, when contested beliefs impede collective action.

The Compounding Effect of Rurality on Health Disparities Among Black Patients with COVID-19.

Background: West Virginia had garnered national attention for its vaccination rollout against coronavirus 2019 (COVID-19). Outcomes of this mostly rural population, however, have been underreported. As the pandemic continues, identifying high risk populations remains important to further epidemiologic information and target vaccines. Purpose: The objective of this study is to examine the effects of COVID-19 and the influence of race and rurality on hospitalization and outcomes in Appalachians. Methods: In this retrospective study, data from patients who tested positive and were admitted for COVID-19 and seen within the state's largest health system (West Virginia University Health System) between March 18 and September 16, 2020 were analyzed. Cases were stratified into rural or urban based on rural urban continuum codes (RUCCs) and by race into 'white,' 'black,' or 'other.' Associations between rurality, rurality and race, and outcomes were assessed. Results: A total of 2011 adult West Virginians tested positive, of which 8.2% were hospitalized. Of the hospitalized patients, 33.5% were rural and 11.6% were black. Rural black patients were three times more likely (OR: 3.33; 95%CI:1.46-7.60) to be admitted. Rural blacks were also more likely to have a history of obstructive pulmonary disease (OR: 2.73; 1.24-6.01), hypertension (OR: 2.78; 1.38-5.57), and multiple chronic conditions (3.04; 1.48-6.22). Implications: Rural blacks were more likely to have risk factors for severe COVID-19 influencing their increased risk of hospitalization. These findings support that race as a risk factor for severe COVID-19 is compounded by rurality and identifies an important target group for vaccination.

Impacts of the COVID-19 pandemic on rural America.

Despite considerable social scientific attention to the impacts of the COVID-19 pandemic on urbanized areas, very little research has examined its impact on rural populations. Yet rural communities-which make up tens of millions of people from diverse backgrounds in the United States-are among the nation's most vulnerable populations and may be less resilient to the effects of such a large-scale exogenous shock. We address this critical knowledge gap with data from a new survey designed to assess the impacts of the pandemic on health-related and economic dimensions of rural well-being in the North American West. Notably, we find that the effects of the COVID-19 pandemic on rural populations have been severe, with significant negative impacts on unemployment, overall life satisfaction, mental health, and economic outlook. Further, we find that these impacts have been generally consistent across age, ethnicity, education, and sex. We discuss how these findings constitute the beginning of a much larger interdisciplinary COVID-19 research effort that integrates rural areas and pushes beyond the predominant focus on cities and nation-states.

COVID-19 Death Rates Are Higher in Rural Counties With Larger Shares of Blacks and Hispanics.

PURPOSE: This study compared the average daily increase in COVID-19 mortality rates by county racial/ethnic composition (percent non-Hispanic Black and percent Hispanic) among US rural counties. METHODS: COVID-19 daily death counts for 1,976 US nonmetropolitan counties for the period March 2-July 26, 2020, were extracted from USAFacts and merged with county-level American Community Survey and Area Health Resource File data. Covariates included county percent poverty, age composition, adjacency to a metropolitan county, health care supply, and state fixed effects. Mixed-effects negative binomial regression with random intercepts to account for repeated observations within counties were used to predict differences in the average daily increase in the COVID-19 mortality rate across quartiles of percent Black and percent Hispanic. FINDINGS: Since early March, the average daily increase in the COVID-19 mortality rate has been significantly higher in rural counties with the highest percent Black and percent Hispanic populations. Compared to counties in the bottom quartile, counties in the top quartile of percent Black have an average daily increase that is 70% higher (IRR = 1.70, CI: 1.48-1.95, P < .001), and counties in the top quartile of percent Hispanic have an average daily increase that is 50% higher (IRR = 1.50, CI: 1.33-1.69, P < .001), net of covariates. CONCLUSION: COVID-19 mortality risk is not distributed equally across the rural United States, and the COVID-19 race penalty is not restricted to cities. Among rural counties, the average daily increase in COVID-19 mortality rates has been significantly higher in counties with the largest shares of Black and Hispanic residents.

The effect of big-city news on rural America during the COVID-19 pandemic.

Can "urban-centric" local television news coverage of the COVID-19 pandemic affect the behavior of rural residents with lived experiences so different from their "local" news coverage? Leveraging quasi-random geographic variation in media markets for 771 matched rural counties, we show that rural residents are more likely to practice social distancing if they live in a media market that is more impacted by COVID-19. Individual-level survey responses from residents of these counties confirm county-level behavioral differences and help attribute the differences we identify to differences in local television news coverage-self-reported differences only exist among respondents who prefer watching local news, and there are no differences in media usage or consumption across media markets. Although important for showing the ability of local television news to affect behavior despite urban-rural differences, the media-related effects we identify are at most half the size of the differences related to partisan differences.

Green Care: A Review of the Benefits and Potential of Animal-Assisted Care Farming Globally and in Rural America.

The term Green Care includes therapeutic, social or educational interventions involving farming; farm animals; gardening or general contact with nature. Although Green Care can occur in any setting in which there is interaction with plants or animals, this review focuses on therapeutic practices occurring on farms. The efficacy of care farming is discussed and the broad utilization of care farming and farm care communities in Europe is reviewed. Though evidence from care farms in the United States is included in this review, the empirical evidence which could determine its efficacy is lacking. For example, the empirical evidence supporting or refuting the efficacy of therapeutic horseback riding in adults is minimal, while there is little non-equine care farming literature with children. The health care systems in Europe are also much different than those in the United States. In order for insurance companies to cover Green Care techniques in the United States, extensive research is necessary. This paper proposes community-based ways that Green Care methods can be utilized without insurance in the United States. Though Green Care can certainly be provided in urban areas, this paper focuses on ways rural areas can utilize existing farms to benefit the mental and physical health of their communities.