Are Guideline-concordant Processes of Care Consistent Across the Rural-Urban Continuum? A Retrospective Cohort Study of Adults Newly Treated for Type 2 Diabetes.

OBJECTIVES: Our aim in this study was to identify the association between place of residence (metropolitan, urban, rural) and guideline-concordant processes of care in the first year of type 2 diabetes management. METHODS: We conducted a retrospective cohort study of new metformin users between April 2015 and March 2020 in Alberta, Canada. Outcomes were identified as guideline-concordant processes of care through the review of clinical practice guidelines and published literature. Using multivariable logistic regression, the following outcomes were examined by place of residence: dispensation of a statin, angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB), eye examination, glycated hemoglobin (A1C), cholesterol, and kidney function testing. RESULTS: Of 60,222 new metformin users, 67% resided in a metropolitan area, 10% in an urban area, and 23% in a rural area. After confounder adjustment, rural residents were less likely to have a statin dispensed (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.79 to 0.87) or undergo cholesterol testing (aOR 0.86, 95% CI 0.83 to 0.90) when compared with metropolitan residents. In contrast, rural residents were more likely to receive A1C and kidney function testing (aOR 1.14, 95% CI 1.08 to 1.21 and aOR 1.17, 95% CI 1.11 to 1.24, respectively). ACEi/ARB use and eye examinations were similar across place of residence. CONCLUSIONS: Processes of care varied by place of residence. Limited cholesterol management in rural areas is concerning because this may lead to increased cardiovascular outcomes.

Rurality is associated with lower likelihood of dipeptidyl peptidase 4 inhibitor use for treatment intensification.

Background: Antihyperglycemic drug utilization studies are conducted frequently and describe the uptake of new drug therapies across may jurisdictions. An increasingly important, yet often absent, aspect of these studies is the impact of rurality on drug utilization. Objectives: The objective of this study was to explore the association between place of residence (rural, urban, metropolitan) and the use of dipeptidyl peptidase 4 inhibitors (DPP-4i) for first treatment intensification of type 2 diabetes. Methods: A retrospective cohort study was conducted from April 1, 2008 to March 31, 2019 of new metformin users. A multivariable logistic regression analysis was performed to determine the association between place of residence (using postal codes) and likelihood of DPP-4i dispensing. Results: After adjusting for confounders, analysis revealed that rural-dwellers are less likely to have a DPP-4i dispensed, compared with metropolitan-dwellers (aOR:0.64; 95%CI:0.61-0.67) and over-time, the uptake in rural areas was slower. Conclusions: This study demonstrates that rurality can have an impact on drug therapy decisions at first treatment intensification, with respect to the utilization of new therapies.

Staphylococcus aureus Bacteremia in Pediatric Patients: Uncovering a Rural Health Challenge.

Background: Staphylococcus aureus bacteremia poses significant risk for morbidity and mortality. This may be exacerbated in rural populations facing unique health challenges. Methods: To investigate factors influencing S. aureus bacteremia outcomes, we conducted a retrospective cohort study of children admitted to St. Louis Children's Hospital (SLCH) from 2011 to 2019. Exposures included rurality (defined by the Rural-Urban Continuum Code), Area Deprivation Index, and outside hospital (OSH) admission before SLCH admission. The primary outcome was treatment failure, a composite of 90-day all-cause mortality and hospital readmission. Results: Of 251 patients, 69 (27%) were from rural areas; 28 (11%) were initially admitted to an OSH. Treatment failure occurred in 39 (16%) patients. Patients from rural areas were more likely to be infected with methicillin-resistant S. aureus (45%) vs urban children (29%; P = .02). Children initially admitted to an OSH, vs those presenting directly to SLCH, were more likely to require intensive care unit-level (ICU) care (57% vs 29%; P = .002), have an endovascular source of infection (32% vs 12%; P = .004), have a longer duration of illness before hospital presentation (4.1 vs 3.0 days; P = .04), and have delayed initiation of targeted antibiotic therapy (3.9 vs 2.6 days; P = .01). Multivariable analysis revealed rural residence (adjusted odds ratio [aOR], 2.3; 95% CI, 1.1-5.0), comorbidities (aOR, 2.9; 95% CI, 1.3-6.2), and ICU admission (aOR, 3.9; 95% CI, 1.9-8.3) as predictors of treatment failure. Conclusions: Children from rural areas face barriers to specialized health care. These challenges may contribute to severe illness and worse outcomes among children with S. aureus bacteremia.

Urbanicity and cognitive functioning in later life.

Introduction: Prior research has shown disparities in cognitive functioning across the rural-urban continuum. We examine individual- and contextual-level factors to understand how and why urbanicity shapes cognitive functioning across older adulthood. Methods: Using a nationally representative sample from 1996 to 2016 waves of the Health and Retirement Study (HRS) and growth curve models, we assess urban-suburban-exurban differences in older adult cognitive functioning. Results: Results demonstrate that older adult men and women living in exurban areas, and older adult men in suburban areas, have lower cognitive functioning scores compared to their urban peers. Educational attainment and marital status contribute to but do not fully explain these differences. There were no differences in the trajectory over age, suggesting that urbanicity disparities in cognition occur earlier in life, with average differences remaining the same across older adulthood. Discussion: Differences in cognitive functioning across urbanicity are likely due to factors accumulating prior to older adulthood.

Racial/Ethnic Heterogeneity and Rural-Urban Disparity of COVID-19 Case Fatality Ratio in the USA: a Negative Binomial and GIS-Based Analysis.

The 2019 coronavirus disease (COVID-19) has exacerbated inequality in the United States of America (USA). Black, indigenous, and people of color (BIPOC) are disproportionately affected by the pandemic. This study examines determinants of COVID-19 case fatality ratio (CFR) based on publicly sourced data from January 1 to December 18, 2020, and sociodemographic and rural-urban continuum data from the US Census Bureau. Nonspatial negative binomial Poisson regression and geographically weighted Poisson regression were applied to estimate the global and local relationships between the CFR and predictors-rural-urban continuum, political inclination, and race/ethnicity in 2407 rural counties. The mean COVID-19 CFR among rural counties was 1.79 (standard deviation (SD) = 1.07; 95% CI 1.73-1.84) higher than the total US counties (M = 1.69, SD = 1.18; 95% CI: 1.65-1.73). Based on the global NB model, CFR was positively associated with counties classified as "completely rural" (incidence rate ratio (IRR) = 1.24; 95% CI: 1.12-1.39) and "mostly rural" (IRR = 1.26; 95% CI: 1.15-1.38) relative to "mostly urban" counties. Nonspatial regression indicates that COVID-19 CFR increases by a factor of 8.62, 5.87, 2.61, and 1.36 for one unit increase in county-level percent Blacks, Hispanics, American Indians, and Asian/Pacific Islanders, respectively. Local spatial regression shows CFR was significantly higher in rural counties with a higher share of BIPOC in the Northeast and Midwest regions, and political inclination predicted COVID-19 CFR in rural counties in the Midwest region. In conclusion, spatial and racial/ethnic disparities exist for COVID-19 CFR across the US rural counties, and findings from this study have implications for public health.

Rural-urban and within-rural differences in COVID-19 vaccination rates.

PURPOSE: COVID-19 mortality rates are higher in rural versus urban areas in the United States, threatening to exacerbate the existing rural mortality penalty. To save lives and facilitate economic recovery, we must achieve widespread vaccination coverage. This study compared adult COVID-19 vaccination rates across the US rural-urban continuum and across different types of rural counties. METHODS: We retrieved vaccination rates as of August 11, 2021, for adults aged 18+ for the 2,869 counties for which data were available from the CDC. We merged these with county-level data on demographic and socioeconomic composition, health care infrastructure, 2020 Trump vote share, and USDA labor market type. We then used regression models to examine predictors of COVID-19 vaccination rates across the USDA's 9-category rural-urban continuum codes and separately within rural counties by labor market type. FINDINGS: As of August 11, 45.8% of adults in rural counties had been fully vaccinated, compared to 59.8% in urban counties. In unadjusted regression models, average rates declined monotonically with increasing rurality. Lower rural rates are explained by a combination of lower educational attainment and higher Trump vote share. Within rural counties, rates are lowest in farming and mining-dependent counties and highest in recreation-dependent counties, with differences explained by a combination of educational attainment, health care infrastructure, and Trump vote share. CONCLUSION: Lower vaccination rates in rural areas is concerning given higher rural COVID-19 mortality rates and recent surges in cases. At this point, mandates may be the most effective strategy for increasing vaccination rates.

Global mapping of urban-rural catchment areas reveals unequal access to services.

Using travel time to cities of different sizes, we map populations across an urban-rural continuum to improve on the standard dichotomous representations of urban-rural interactions. We extend existing approaches by 1) building on central place theory to capture the urban hierarchy in access to services and employment opportunities provided by urban centers of different sizes, 2) defining urban-rural catchment areas (URCAs) expressing the interconnection between urban centers and their surrounding rural areas, and 3) adopting a global gridded approach comparable across countries. We find that one-fourth of the global population lives in periurban areas of intermediate and smaller cities and towns, which challenges the centrality of large cities in development. In low-income countries, 64% of the population lives either in small cities and towns or within their catchment areas, which has major implications for access to services and employment opportunities. Intermediate and small cities appear to provide catchment areas for proportionately more people gravitating around them than larger cities. This could indicate that, for countries transitioning to middle income, policies and investments strengthening economic linkages between urban centers and their surrounding rural areas may be as important as investing in urbanization or the rural hinterlands. The dataset provided can support national economic planning and territorial development strategies by enabling policy makers to focus more in depth on urban-rural interactions.

What is the availability, affordability, and quality of foods and beverages aligned with dietary guidance in Louisiana Supplemental Nutrition Assistance Program (SNAP) authorized stores?

Healthy food retail strategies are delivered by Cooperative Extension Services in Louisiana to improve public health among communities with lower income. To guide Cooperative Extension Services Programming, the aim of this study was to assess healthy food access among SNAP-authorized stores. This included comparing the availability, affordability, and quality of healthy foods sold in these stores by geography, ownership, and store type. Seventy-five Louisiana SNAP-authorized stores were selected for measurement. Between October 2019 and March 2020 (prior to the COVID-19 national emergency declaration), trained researchers used the Nutrition Environment Measures Survey in Stores (NEMS-S) to assess the availability, affordability, and quality of healthy versus less healthy foods and beverages in 42 SNAP-authorized stores, including: grocery (n = 12, 29%), convenience (n = 17, 41%), drug (n = 1, 2%), dollar (n = 11, 26%), and butcher/meat (n = 1, 2%). Multivariate analysis of variance (a priori, p < 0.05) determined if differences in total NEMS-S scores or subscores existed by geography (urban versus rural), ownership (corporate/chain versus independent), or store type. No urban/rural differences were identified. Corporate/chain SNAP-authorized stores scored higher on average than independent SNAP-authorized stores for the total NEMS-S score (17.2 versus 8.1; p = 0.009) and availability subscore (13.1 versus 6.1; p = 0.02). SNAP-authorized grocery stores scored higher than all other store types (total NEMS-S score 27.6), followed by SNAP-authorized dollar stores (total NEMS-S score 10.7), and SNAP-authorized convenience stores (total NEMS-S score 5) (p < 0.001). Louisiana Cooperative Extension Services should explore ways to scale healthy food retail strategies statewide with a specific emphasis on independent and smaller SNAP-authorized retailers.

Global Harmonization of Urbanization Measures: Proceed with Care.

By 2050, two-thirds of the world's population is expected to be living in cities and towns, a marked increase from today's level of 55 percent. If the general trend is unmistakable, efforts to measure it precisely have been beset with difficulties: the criteria defining urban areas, cities and towns differ from one country to the next and can also change over time for any given country. The past decade has seen great progress toward the long-awaited goal of scientifically comparable urbanization measures, thanks to the combined efforts of multiple disciplines. These efforts have been organized around what is termed the "statistical urbanization" concept, whereby urban areas are defined by population density, contiguity and total population size. Data derived from remote-sensing methods can now supply a variety of spatial proxies for urban areas defined in this way. However, it remains to be understood how such proxies complement, or depart from, meaningful country-specific alternatives. In this paper, we investigate finely resolved population census and satellite-derived data for the United States, Mexico and India, three countries with widely varying conceptions of urban places and long histories of debate and refinement of their national criteria. At the extremes of the urban-rural continuum, we find evidence of generally good agreement between the national and remote sensing-derived measures (albeit with variation by country), but identify significant disagreements in the middle ranges where today's urban policies are often focused.

Beyond the City: Exploring the Suburban and Rural Landscapes of Racial Residential Integration across the United States.

In recent decades, racial and ethnic diversity has expanded from the city into the suburbs, the rural-urban interface, and remote rural places across all regions in the United States. This study examines how these population trends shape the possibility of racial residential integration across the American rural-urban continuum and regions. Using the information theory index (H) and racial and ethnic composition thresholds, we identify integrated cities, suburbs, and rural towns and villages that are stably integrated between the 2000 and 2010 censuses. This study shows a substantial number of diverse places where people of different races and ethnicities live near each other. Further, the largest clusters of integration locate in suburbs, followed by rural places, while central cities show the lowest rates of integration. In addition, the West typically hosts larger numbers of integrated communities compared to other regions. Findings suggest that to better understand shifting patterns of American racial inequality, research must look outside the city and toward the West to investigate residential integration as a new form of 21st-century race relations.

Minimum Dietary Diversity Scores for Women Indicate Micronutrient Adequacy and Food Insecurity Status in South African Towns.

The lack of dietary diversity is a severe problem experienced by most poor households globally. In particular; women of reproductive age (WRA) are at high risk of inadequate intake of micronutrients resulting from diets dominated by starchy staples. The present study considered the diets, dietary diversity, and food security of women aged 15-49 years along the rural-urban continuum in three South African towns situated along an agro-ecological gradient. A 48 h dietary recall was conducted across two seasons with 554 women from rural, peri-urban, and urban locations of Richards Bay, Dundee, and Harrismith. Minimum Dietary Diversity for WRA (MDD-W) were calculated and a dichotomous indicator based on a set of ten food groups was used to determine if women had consumed at least five food groups the previous 48 h to achieve minimum dietary intake for women. The mean (±sd) MDD-W for Richards Bay (3.78 ± 0.07) was significantly higher than at Dundee (3.21 ± 0.08) and Harrismith (3.36 ± 0.07). Food security and MDD-W were significantly higher in urban locations than in peri-urban or rural ones. There was lower dependence on food purchasing in Richards Bay compared to Dundee and Harrismith. The majority of women in Richards Bay practiced subsistence agriculture, produced a surplus for sale, and collected wild foods which improved dietary intake and food security. The peri-urban populations had limited dietary intake and were more food insecure because of high levels of poverty, unemployment, and lack of land. Peri-urban dwellers are therefore more sensitive to changes in incomes and food prices because they lack safety nets to absorb income or price shocks as they purchase more, rather than growing their own food. This compromises dietary diversity as they have limited access to diverse foods.

Ethnoracial Diversity across the Rural-Urban Continuum.

Both scholarship and popular opinion have long held that cities are more racially and ethnically diverse than rural communities. However, recent trends hint at the potential for less distinctive diversity profiles on either side of the metro-nonmetro divide. To explore this possibility, we compare the magnitude and structure of ethnoracial diversity in 2010 for over 27,000 census-defined places arrayed across 10 different types of county contexts that span the rural-urban continuum. Although the average resident's exposure to diversity steadily declines as contexts become more rural and remote, place-based (or unweighted) results show an uneven pattern of diversity across most of the continuum. Our multivariate analysis also supports the unevenness scenario: when detailed characteristics of places are taken into account, many of the associations between the context indicators and diversity weaken to the point of non-significance. Taken together, these findings suggest a blurring of rural-urban boundaries with respect to community ethnoracial composition.

The differential effects of rural health care access on race-specific mortality.

We examined the relationship between race-specific rural mortality and the health infrastructure of rural counties in light of America's recent emergence of a rural mortality penalty. Using the Compressed Mortality File from National Center for Health Statistics (2008-2012) and county-level demographic, socioeconomic, and health care indicators from the Area Health Resource File and the US Census, we created a rural public health infrastructure index which encompasses four types of health care access (public health employees, critical access hospital/rural referral centers, rural health clinics, and emergency departments) within counties. We found that each unit increase in the index is associated with a decline in rural Black mortality, but is associated with an increase in rural White mortality. Policymakers could benefit from focusing on the declining rate of mortality improvement in many rural regions, specifically by trying to better understand how decisions concerning public health spending may influence mortality differently for Black and White residents.

Household Food Insecurity along an Agro-Ecological Gradient Influences Children's Nutritional Status in South Africa.

The burden of food insecurity and malnutrition is a severe problem experienced by many poor households and children under the age of five are at high risk. The objective of the study was to examine household food insecurity, dietary diversity, and child nutritional status in relation to local context which influences access to and ability to grow food in South Africa and explore the links and associations between these and household socio-economic status. Using a 48-h dietary recall method, we interviewed 554 women from randomly selected households along a rural-urban continuum in three towns situated along an agro-ecological gradient. The Household Dietary Diversity Scores (HDDS) and the Household Food Insecurity Access Scale (HFIAS) tools were used to measure household dietary diversity and food insecurity, respectively. Anthropometric measurements with 216 children (2-5 years) from the sampled households were conducted using height-for-age and mid-upper arm circumference (MUAC) as indicators of stunting and wasting, respectively. The key findings were that mean HDDS declined with decreasing agro-ecological potential from the wettest site (8.44 ± 1.72) to the other two drier sites (7.83 ± 1.59 and 7.76 ± 1.63). The mean HFIAS followed the opposite trend. Stunted growth was the dominant form of malnutrition detected in 35% of children and 18% of children were wasted. Child wasting was greatest at the site with lowest agro-ecological potential. Children from households with low HDDS had large MUAC which showed an inverse association among HDDS and obesity. Areas with agro-ecological potential had lower prevalence of food insecurity and wasting in children. Agro-ecological potential has significant influence on children's nutritional status, which is also related to household food security and socio-economic status. Dependence on food purchasing and any limitations in households' income, access to land and food, can result in different forms of malnutrition in children. Responses to address malnutrition in South Africa need to be prioritized and move beyond relying on food security and nutritional-specific interventions, but rather on nutrition-specific and sensitive programs and approaches; and building an enabling environment. Land availability, agriculture (including climate-smart agriculture especially in drier areas), and wild foods usage should be promoted.

Moving Toward Integration? Effects of Migration on Ethnoracial Segregation Across the Rural-Urban Continuum.

This study analyzes the impact of migration on ethnoracial segregation among U.S. counties. Using county-level net migration estimates by age, race, and Hispanic origin from 1990-2000 and 2000-2010, we estimate migration's impact on segregation by age and across space. Overall, migration served to integrate ethnoracial groups in both decades, whereas differences in natural population change (increase/decrease) would have increased segregation. Age differences, however, are stark. Net migration of the population under age 40 reduced segregation, while net migration of people over age 60 further segregated people. Migration up and down the rural-urban continuum (including suburbanization among people of color) did most to decrease segregation, while interregional migration had only a small impact. People of color tended to move toward more predominantly white counties and regions at all ages. Migration among white young adults (aged 20-39) also decreased segregation. Whites aged 40 and older, however, showed tendencies toward white flight. Moderate spatial variation suggests that segregation is diminishing the most in suburban and fringe areas of several metropolitan areas in the Northeast and Midwest, while parts of the South, Southwest, and Appalachia show little evidence of integration.