Evaluation of respondent-driven sampling in seven studies of people who use drugs from rural populations: findings from the Rural Opioid Initiative.

BACKGROUND: Accurate prevalence estimates of drug use and its harms are important to characterize burden and develop interventions to reduce negative health outcomes and disparities. Lack of a sampling frame for marginalized/stigmatized populations, including persons who use drugs (PWUD) in rural settings, makes this challenging. Respondent-driven sampling (RDS) is frequently used to recruit PWUD. However, the validity of RDS-generated population-level prevalence estimates relies on assumptions that should be evaluated. METHODS: RDS was used to recruit PWUD across seven Rural Opioid Initiative studies between 2018-2020. To evaluate RDS assumptions, we computed recruitment homophily and design effects, generated convergence and bottleneck plots, and tested for recruitment and degree differences. We compared sample proportions with three RDS-adjusted estimators (two variations of RDS-I and RDS-II) for five variables of interest (past 30-day use of heroin, fentanyl, and methamphetamine; past 6-month homelessness; and being positive for hepatitis C virus (HCV) antibody) using linear regression with robust confidence intervals. We compared regression estimates for the associations between HCV positive antibody status and (a) heroin use, (b) fentanyl use, and (c) age using RDS-1 and RDS-II probability weights and no weights using logistic and modified Poisson regression and random-effects meta-analyses. RESULTS: Among 2,842 PWUD, median age was 34 years and 43% were female. Most participants (54%) reported opioids as their drug of choice, however regional differences were present (e.g., methamphetamine range: 4-52%). Many recruitment chains were not long enough to achieve sample equilibrium. Recruitment homophily was present for some variables. Differences with respect to recruitment and degree varied across studies. Prevalence estimates varied only slightly with different RDS weighting approaches, most confidence intervals overlapped. Variations in measures of association varied little based on weighting approach. CONCLUSIONS: RDS was a useful recruitment tool for PWUD in rural settings. However, several violations of key RDS assumptions were observed which slightly impacts estimation of proportion although not associations.

Correlates of Recent HIV Testing Among People Who Inject Drugs in Rural Areas: A Multi-site Cross-Sectional Study, 2018-2020.

The Rural Opioid Initiative surveyed 2693 people who inject drugs (PWID) in eight rural U.S. areas in 2018-2020 about self-reported HIV testing in the past 6 months. Correlates of interest included receipt of any drug-related services, incarceration history, and structural barriers to care (e.g., lack of insurance, proximity to syringe service programs [SSP]). Overall, 20% of participants reported receiving an HIV test within the past 6 months. Multivariable generalized estimating equations showed that attending substance use disorder (SUD) treatment (OR 2.11, 95%CI [1.58, 2.82]), having health insurance (OR 1.42, 95%CI [1.01, 2.00]) and recent incarceration (OR 1.49, 95%CI [1.08, 2.04]) were positively associated with HIV testing, while experiencing a resource barrier to healthcare (inability to pay, lack of transportation, inconvenient hours, or lack of child care) had inverse (OR 0.73, 95%CI [0.56, 0.94]) association with HIV testing. We found that the prevalence of HIV testing among rural PWID is low, indicating an unmet need for testing. While SUD treatment or incarceration may increase chances for HIV testing for rural PWID, other avenues for expanding HIV testing, such as SSP, need to be explored.

The relationship between felt stigma and non-fatal overdose among rural people who use drugs.

BACKGROUND: Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs. METHODS: Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose. RESULTS: 6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14). CONCLUSIONS: Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

Behaviors associated with HIV transmission risk among rural sexual and gender minority and majority residents.

Multiple rural states and communities experience elevated rates of human immunodeficiency virus (HIV), often associated with diminished healthcare access and increased drug use. Though a substantial proportion of rural populations are sexual and gender minorities (SGM), little is known of this group regarding substance use, healthcare utilization, and HIV transmission behaviors. During May-July 2021, we surveyed 398 individuals across 22 rural Illinois counties. Participants included cisgender heterosexual males (CHm) and females (CHf) (n = 110); cisgender non-heterosexual males and females (C-MSM and C-WSW; n = 264); and transgender individuals (TG; n = 24). C-MSM participants were more likely to report daily-to-weekly alcohol and illicit drug use prescription medication misuse (versus CHf; aOR = 5.64 [2.37-13.41], 4.42 [1.56-12.53], and 29.13 [3.80-223.20], respectively), and C-MSM participants more frequently reported traveling to meet with romantic/sex partners. Further, more C-MSM and TG than C-WSW reported healthcare avoidance and denial due to their orientation/identity (p < 0.001 and p = 0.011, respectively); 47.6% of C-MSM and 58.3% of TG had not informed their provider about their orientation/identity; and only 8.6% of C-MSM reported ever receiving a pre-exposure prophylaxis (PrEP) recommendation. More work is needed to explore the substance use and sexual behaviors of rural SGM, as well as their healthcare interactions, to better target health and PrEP engagement campaigns.

Houselessness and syringe service program utilization among people who inject drugs in eight rural areas across the USA: a cross-sectional analysis.

BACKGROUND: Research conducted in urban areas has highlighted the impact of housing instability on people who inject drugs (PWID), revealing that it exacerbates vulnerability to drug-related harms and impedes syringe service program (SSP) use. However, few studies have explored the effects of houselessness on SSP use among rural PWID. This study examines the relationship between houselessness and SSP utilization among PWID in eight rural areas across 10 states. METHODS: PWID were recruited using respondent-driven sampling for a cross-sectional survey that queried self-reported drug use and SSP utilization in the prior 30 days, houselessness in the prior 6 months and sociodemographic characteristics. Using binomial logistic regression, we examined the relationship between experiencing houselessness and any SSP use. To assess the relationship between houselessness and the frequency of SSP use, we conducted multinomial logistic regression analyses among participants reporting any past 30-day SSP use. RESULTS: Among 2394 rural PWID, 56.5% had experienced houselessness in the prior 6 months, and 43.5% reported past 30-day SSP use. PWID who had experienced houselessness were more likely to report using an SSP compared to their housed counterparts (adjusted odds ratio [aOR] = 1.24 [95% confidence intervals [CI] 1.01, 1.52]). Among those who had used an SSP at least once (n = 972), those who experienced houselessness were just as likely to report SSP use two (aOR = 0.90 [95% CI 0.60, 1.36]) and three times (aOR = 1.18 [95% CI 0.77, 1.98]) compared to once. However, they were less likely to visit an SSP four or more times compared to once in the prior 30 days (aOR = 0.59 [95% CI 0.40, 0.85]). CONCLUSION: This study provides evidence that rural PWID who experience houselessness utilize SSPs at similar or higher rates as their housed counterparts. However, housing instability may pose barriers to more frequent SSP use. These findings are significant as people who experience houselessness are at increased risk for drug-related harms and encounter additional challenges when attempting to access SSPs.

Attitudes toward harm reduction and low-threshold healthcare during the COVID-19 pandemic: qualitative interviews with people who use drugs in rural southern Illinois.

BACKGROUND: Chronic health conditions associated with long-term drug use may pose additional risks to people who use drugs (PWUD) when coupled with COVID-19 infection. Despite this, PWUD, especially those living in rural areas, may be less likely to seek out health services. Previous research has highlighted the increased disease burden of COVID-19 among PWUD. Our manuscript supplements this literature by exploring unique attitudes of PWUD living in rural areas toward the pandemic, COVID-19 vaccination, and the role of harm reduction (HR) organizations in raising health awareness among PWUD. METHODS: Semi-structured interviews were conducted with 20 PWUD living in rural southern Illinois. Audio recordings were professionally transcribed. A preliminary codebook was created based on interview domains. Two trained coders conducted iterative coding of the transcripts, and new codes were added through line-by-line coding and thematic grouping. RESULTS: Twenty participants (45% female, mean age of 38) completed interviews between June and November 2021. Participants reported negative impacts of the pandemic on mental health, financial wellbeing, and drug quality. However, the health impacts of COVID-19 were often described as less concerning than its impacts on these other aspects of life. Many expressed doubt in the severity of COVID-19 infection. Among the 16 unvaccinated participants who reported receiving most of their information from the internet or word of mouth, uncertainty about vaccine contents and distrust of healthcare and government institutions engendered wariness of the vaccination. Distrust of healthcare providers was related to past stigmatization and judgement, but did not extend to the local HR organization, which was unanimously endorsed as a positive institution. Among participants who did not access services directly from the HR organization, secondary distribution of HR supplies by other PWUD was a universally cited form of health maintenance. Participants expressed interest in low-threshold healthcare, including COVID-19 vaccination, should it be offered in the local HR organization's office and mobile units. CONCLUSION: COVID-19 and related public health measures have affected this community in numerous ways. Integrating healthcare services into harm reduction infrastructures and mobilizing secondary distributors of supplies may promote greater engagement with vaccination programs and other healthcare services. TRIAL NUMBER: NCT04427202.

Sexually Transmitted Infection Epidemiology and Care in Rural Areas: A Narrative Review.

BACKGROUND: Although rural areas contain approximately 19% of the US population, little research has explored sexually transmitted infection (STI) risk and how urban-developed interventions may be suitable in more population-thin areas. Although STI rates vary across rural areas, these areas share diminishing access to screening and limited rural-specific testing of STI interventions. METHODS: This narrative review uses a political ecology model of health and explores 4 domains influencing STI risk and screening: epidemiology, health services, political and economic, and social. Articles describing aspects of rural STI epidemiology, screening access and use, and intervention utility within these domains were found by a search of PubMed. RESULTS: Epidemiology contributes to risk via multiple means, such as the presence of increased-risk populations and the at-times disproportionate impact of the opioid/drug use epidemic. Rural health services are diminishing in quantity, often have lesser accessibility, and may be stigmatizing to those needing services. Local political and economic influences include funding decisions, variable enforcement of laws/statutes, and systemic prevention of harm reduction services. Social norms such as stigma and discrimination can prevent individuals from seeking appropriate care, and also lessen individual self-efficacy to reduce personal risk. CONCLUSIONS: Sexually transmitted infection in rural areas is significant in scope and facing diminished prevention opportunities and resources. Although many STI interventions have been developed and piloted, few have been tested to scale or operationalized in rural areas. By considering rural STI risk reduction within a holistic model, purposeful exploration of interventions tailored to rural environments may be explored.

Cancer screening utilization by residence and sexual orientation.

PURPOSE: Although few studies have examined screening uptake among sexual minorities (lesbian, gay, bisexual, queer), almost none have examined it in the specific context of rural populations. Therefore, our objective was to assess how cancer screening utilization varies by residence and sexual orientation. METHODS: Publicly available population-level data from the 2014 and 2016 Behavioral Risk Factor Surveillance System were utilized. Study outcomes included recommended recent receipt of breast, cervical, and colorectal cancer screening. Independent variables of interest were residence (rural/urban) and sexual orientation (heterosexual/gay or lesbian/bisexual). Weighted proportions and multivariable logistic regressions were used to assess the association between the independent variables and the outcomes, adjusting for demographic, socioeconomic, and healthcare utilization factors. RESULTS: Rates for all three cancer screenings were lowest in rural areas and among sexual minority populations (cervical: rural lesbians at 64.8% vs. urban heterosexual at 84.6%; breast: rural lesbians at 66.8% vs. urban heterosexual at 80.0%; colorectal for males: rural bisexuals at 52.4% vs. urban bisexuals at 81.3%; and colorectal for females: rural heterosexuals at 67.2% vs. rural lesbians at 74.4%). In the multivariate analyses for colorectal screening, compared to urban heterosexual males, both rural gay and rural heterosexual males were less likely to receive screening (aOR = 0.45; 95% = 0.24-0.73 and aOR = 0.79; 95% = 0.72-0.87, respectively) as were rural heterosexual females (aOR = 0.87; 95% = 0.80-0.94) compared to urban heterosexual females. For cervical screening, lesbians were less likely to receive screening (aOR = 0.62; 95% = 0.41-0.94) than heterosexuals, and there were no differences for breast screening. CONCLUSION: We found that rural sexual minorities may experience disparities in cancer screening utilization associated with the compounding barriers of rural residence and sexual minority status, after adjusting for demographic, socioeconomic, and healthcare utilization factors. Further work is needed to identify factors influencing these disparities and how they might be addressed.

How the evolving epidemics of opioid misuse and HIV infection may be changing the risk of oral sexually transmitted infection risk through microbiome modulation.

The epidemiology of sexually transmitted infections (STI) is constantly evolving, and the mechanisms of infection risk in the oral cavity (OC) are poorly characterized. Evidence indicates that microbial community (microbiota) compositions vary widely between the OC, genitalia and the intestinal and rectal mucosa, and microbiome-associated STI susceptibility may also similarly vary. The opioid misuse epidemic is at an epidemic scale, with >11 million US residents misusing in the past 30 days. Opioids can substantially influence HIV progression, microbiota composition and immune function, and these three factors are all mutually influential via direct and indirect pathways. While many of these pathways have been explored independently, the supporting data are mostly derived from studies of gut and vaginal microbiotas and non-STI infectious agents. Our purpose is to describe what is known about the combination of these pathways, how they may influence microbiome composition, and how resultant oral STI susceptibility may change. A better understanding of how opioid misuse influences oral microbiomes and STI risk may inform better mechanisms for oral STI screening and intervention. Further, the principles of interaction described may well be applied to other aspects of disease risk of other health conditions which may be impacted by the opioid epidemic.

Palliative care knowledge, information sources, and beliefs: Results of a national survey of adults in the USA.

OBJECTIVE: Despite its established benefits, palliative care (PC) is not well known among patients and family/caregivers. From a nationally representative survey, we sought to assess the following associated with PC: knowledge, knowledge sources, and beliefs. METHODS: Data were drawn from the Health Information National Trends Study (HINTS 5 Cycle 2), a cross-sectional, survey of non-institutionalized adults aged 18+ years in the USA. Data were weighted and assessed by proportional comparison and multivariable logistic regression. RESULTS: A total of 3504 respondents were identified, and approximately 29% knew about PC. In the adjusted model, less PC knowledge was associated with: lower age (those aged <50), male gender, lower education (

Population Structure Analyses Provide Insight into the Source Populations Underlying Rural Isolated Communities in Illinois.

We have previously hypothesized that relatively small and isolated rural communities may experience founder effects, defined as the genetic ramifications of small population sizes at the time of a community's establishment. To explore this, we used an Illumina Infinium Omni2.5Exome-8 chip to collect data from 157 individuals from four Illinois communities, three rural and one urban. Genetic diversity estimates of 999,259 autosomal markers suggested that the reduction in heterozygosity due to shared ancestry was approximately 0, indicating a randomly mating population. An eigenanalysis, which is similar to a principal component analysis but run on a genetic coancestry matrix, conducted in the SNPRelate R package revealed that most of these individuals formed one cluster, with a few putative outliers obscuring population variation. An additional eigenanalysis on the same markers in a combined data set including the 2,504 individuals in the 1000 Genomes database found that most of the 157 Illinois individuals clustered into one group in close proximity to individuals of European descent. A final eigenanalysis of the Illinois individuals with the 503 individuals of European descent (within the 1000 Genomes Project) revealed two clusters of individuals and likely two source populations; one British and one consisting of multiple European subpopulations. We therefore demonstrate the feasibility of examining genetic relatedness across Illinois populations and assessing the number of source populations using publicly available databases. When assessed, population structure information can contribute to the understanding of genetic history in rural populations.

Sexually transmitted infections in the Delta Regional Authority: significant disparities in the 252 counties of the eight-state Delta Region Authority.

OBJECTIVE: Chlamydia, gonorrhoea and syphilis (primary and secondary) are at high levels in the USA. Disparities by race, gender and sexual orientation have been characterised, but while there are indications that rural poor populations may also be at distinct risk this has been subjected to little study by comparison. The federally designated Delta Regional Authority, similar in structure to the Appalachian Regional Commission, oversees 252 counties within eight Mississippi Delta states experiencing chronic economic and health disparities. Our objective was to identify differences in infection risk between Delta Region (DR)/non-DR counties and examine how they might vary by rurality, population density, primary care access and education attainment. METHODS: Reported chlamydia/gonorrhoea/syphilis data were obtained from the Centers for Disease Control and Prevention AtlasPlus, county demographic data from the Area Health Resource File and rurality classifications from the Department of Agriculture. Data were subjected to analysis by t-test, χ2 and linear regression to assess geographical disparities in incidence and their association with measures of rurality, population and primary care density, and education. RESULTS: Overall rates for each infection were significantly higher in DR versus non-DR counties (577.8 vs 330.1/100 000 for chlamydia; 142.8 vs 61.8 for gonorrhoea; 3.6 vs 1.7 for syphilis; all P<0.001) and for nearly every infection for every individual state. DR rates for each infection were near-universally significantly increased for every level of rurality (nine levels) and population density (quintiles). Regression found that primary care and population density and HS graduation rates were significantly associated with each, though model predictive abilities were poor. CONCLUSIONS: The nearly 10 million people living in the DR face significant disparities in the incidence of chlamydia, gonorrhoea and syphilis-in many instances a near-doubling of risk. Our findings suggest that resource-constrained areas, as measured by rurality, should be considered a priority for future intervention efforts.

Rural Women's Perceptions About Cancer Disparities and Contributing Factors: a Call to Communication.

Rural cancer disparities are increasingly documented in the USA. Research has identified and begun to address rural residents' cancer knowledge and behaviors, especially among women. Little, however, is known about rural female residents' awareness of cancer inequities and perceived contributing factors affecting them and their families. The purpose of this study was to address these gaps in the literature via a secondary analysis of qualitative needs assessment in Illinois' rural southernmost seven counties, a geographic region with relatively high rates of cancer incidence, morbidity, and mortality. A convenience sample of 202 rural adult female residents was recruited and participated in 26 focus groups, with 3-13 women per group. Inductive content analysis, guided by the principle of constant comparison, was used to analyze the qualitative data. Most respondents indicated their awareness of disproportionate cancer burden in their communities. Individual-level behaviors and environmental toxins were identified as contributing factors. Interestingly, however, environmental toxins were more often discussed as factors contributing to geographic differences, whereas individual-level behaviors were noted as important for overall cancer prevention and control. This study provides important insight into female rural residents' perspectives and offers novel venues for educational programs and research in the context of communication to eliminate disparities.

Evolving disparities in the epidemiology of oral cavity and oropharyngeal cancers.

Incidence rates of head and neck cancers (HNC) associated with human papillomavirus (HPVa) infection are increasing while non-HPV-associated (non-HPVa) HNC cancer rates are decreasing. As nearly all sexually active individuals will acquire an HPV infection, it is important to understand epidemiologic trends of HNCs associated with this sexually transmitted disease. We analyzed SEER 9 (1973-2012) and 18 data (2000-2012) for HPVa HNCs (oropharynx area; OP) and non-HPVa (oral cavity area; OC). Incidence rates were examined by gender, race, rurality, geographic location, and time. Joinpoint regression analyses assessed temporal variations. From 1973 to 2012, OC incidence decreased while OP increased, with changes largely driven by males (whose OP rate increased 106.2% vs female decrease of 10.3%). Males consistently had higher rates of both cancer groups across each registry except Alaska, OP rates among blacks changed from significantly above whites to below, and trend analysis indicated significant differences in rates over time by gender, race, and geography. Analysis of SEER 18 found that rates discordantly varied by group and gender across the 18 registries, as did the male/female rate ratio with overall means of 4.7 for OP versus 1.7 for OC (only Alaska and Georgia having overlapping ranges). Our findings indicate that much of the HPVa rate increases were driven by rate increases among males and that there were changing differences in risk between genders, race, and geographic location. The epidemiology of HNCs is complex, with locally relevant factors requiring further research for elucidation of demographic disparities in incidence.

Perceived Harms and Social Norms in the Use of Electronic Cigarettes and Smokeless Tobacco.

Perceptions of harms and social norms influence the use of conventional tobacco cigarettes, but little research is available about their combined relationship with e-cigarette and smokeless tobacco use. We conducted a cross-sectional survey of 309 individuals from central Illinois. We explored (1) demographic predictors of perceived harms and social norms related to e-cigarette and smokeless tobacco use, and (2) whether perceived harms, social norms, or both were important predictors of e-cigarette and smokeless tobacco use. E-cigarette perceptions of harm were consistent across all demographic characteristics. Smokeless tobacco perceptions of harm were unrelated to age, race, and sex, but lower education and income were associated with lower perceived harm (p < .05). E-cigarette social norms were less favorable among non-whites (p < .05) but did not vary by other demographic characteristics. Only less education was associated with more favorable social norms of smokeless tobacco (p < .05). Higher perceived harms were related to lower use of e-cigarettes and smokeless tobacco (p < .05). Perceived social norms were not associated with product use. This study provides preliminary support for implementing broad-based health messaging efforts that focus more on the potential harms of e-cigarette and smokeless tobacco use than on social norms.

The Mini Report: a Practical Tool to Address Lung Cancer Disparities in Rural Communities.

Community-based participatory research (CBPR) is an effective way to address cancer disparities in medically underserved populations. Our research demonstrates how CBPR principles were used to develop lung cancer and risk factor mini reports for a network of community coalitions in the Illinois Delta Region, a predominately rural region with high lung cancer disparities in southern Illinois. An academic-community partnership, including a community-based medical school, state public health department, and a healthcare system, used CBPR principles to translate epidemiological, behavioral, and demographic data into understandable, comprehensive, yet concise mini reports for each coalition. A cyclical and iterative process was used to draft, revise, and optimize these mini reports to raise awareness about lung cancer disparities in the community and to provide information to help guide the development of interventions that address these disparities. The use of CBPR principles was a successful way to create mini reports about local lung cancer disparities and risk factors that were usable in individual communities. Local coalitions used the mini reports to educate community members at local meetings, to guide strategic planning, and to disseminate information through their respective websites. Additionally, the process of creating these reports built trust among academic-community partners and provided additional avenues of engagement, such as the involvement of an academic partner in the strategic planning process of a local coalition. Using CBPR processes is an effective way to translate epidemiological data into a community-friendly format to address cancer disparities.

Young adults with depression are at increased risk of sexually transmitted disease.

Sexually transmitted diseases (STDs) and depression impact millions of individuals each year in the United States, with direct medical costs exceeding $41 billion. While the interactions of these conditions are poorly understood, they are increasingly addressed in primary care whereas historically they have been addressed separately. We analyzed data associated with the 18-25year age group from the 2014 National Survey of Drug Use and Health, a cross-sectional survey of the civilian, non-institutionalized US population aged ≥12years for factors associated with past year diagnosis of STD (STDy). Independent variables included participant demographics; lifetime diagnosis of major depressive episode (MDE); participant behaviors associated with STD risk (patient-provided); and medical record data associated with mental illness treatment (clinically-observed). Of 18,142 participants, the prevalence of MDE and STD was 15.3% and 2.4%, respectively, with significant differences by gender and race. MDE was associated with increased risk of STDy among females (odds ratio [OR]=1.61; 95% confidence interval [CI]=1.18-2.20), males (OR=2.32; CI=1.15-4.70), those of white race (OR=3.02; CI=2.02-4.53), and lower income levels and insurance status. Univariate modeling found that receiving mental health treatment, and use of marijuana, alcohol, and illegal drugs were each associated with significantly increased STDy. In a multivariate logistic regression, receiving mental health treatment became protective for STDy (AOR=0.55; CI=0.32-0.95]). Individuals with a history of depression are at increased risk of STDy, with this risk modified by factors readily ascertained within primary care. As depression treatment is increasingly incorporated into primary care there are means to more effectively target intervention resources.

Comparison of Cancer-specific and General Health Literacy Assessments in an Educated Population: Correlations and Modifying Factors.

An information onslaught accompanies cancer diagnoses, but patient comprehension (health literacy; HL) is frequently low, impacting both immediate care and longer term follow-up. Knowledge and adoption of preventive measures is especially important for cancer survivors due to their increased risk of secondary malignant neoplasms. We sought to evaluate the Test of Functional Health Literacy Adult (S-TOFHLA) against the recently developed cancer-specific Cancer Message Literacy Test (CMLT-r) among an educated population of both cancer survivors and those cancer-free. Participants were recruited 2013 (May through December) from various units within a local hospital and from several local churches, and each completed the S-TOFHLA and CMLT-r and provided demographic information and cancer status. The 109 participants had a mean age of 58 years and were as follows: 65.1 % female; 92.7 % white, 50.4 % college graduates, and 41.3 % cancer survivors. S-TOFHLA scores ranged from 12-36 (mean 34.1) and non-significantly varied by gender, education, cancer status, and age. CMLT-r scores ranged from 28.6-100 % (mean 86.4 %) and significantly varied by education (p = 0.013), but not by gender, cancer status, or age. Overall, CMLT-r and S-TOFHLA significantly correlated (p < 0.001). Assessment scores were skewed towards the maximum with non-significant differences by cancer status. As cancer survivorship improves and as the population becomes more educated, more refined approaches to assess health literacy should be considered. Increased education does not imply increased health literacy, and cancer survivorship does not imply higher health or cancer literacy. Concerted efforts to improve patient understanding and implementation of preventive measures are imperative.

Intrastate Variations in Rural Cancer Risk and Incidence: An Illinois Case Study.

CONTEXT: Although rural-urban cancer disparities have been explored with some depth, disparities within seemingly homogeneous rural areas have received limited attention. However, exploration of intrarural cancer incidence may have important public health implications for risk assessment, cancer control, and resource allocation. OBJECTIVE: The objective of this study was to explore intrastate rural cancer risk and incidence differences within Illinois. DESIGN: Illinois's 83 rural counties were categorized into northern, central, and southern regions (IL-N, IL-C, and IL-S, respectively). Chi-square test for independence and analysis of variance calculations were performed to assess regional differences in demographic characteristics, socioeconomic deprivation, smoking history, obesity, cancer-screening adherence, and density of general practitioners. Age-adjusted incidence rates were calculated for 5 cancer categories: all cancers combined, lung, colorectal, breast (female), and prostate cancers. Unadjusted and adjusted incidence rate ratios (IRRs) were calculated to evaluate regional differences in rates for each cancer category. RESULTS: Socioeconomic deprivation varied by region: 4.5%, 6.9%, and 40.6% of IL-N, IL-C, and IL-S counties, respectively (P < .001). Smoking history also significantly differed by region. Mean former/current smoking prevalence in IL-N, IL-C, and IL-S counties was 46.4%, 48.2%, and 51.4%, respectively (P = .006). In unadjusted analysis, IL-C (IRR = 1.12; 95% confidence interval [CI], 1.02-1.23) and IL-S (IRR = 1.24; 95% CI, 1.13-1.35) had increased lung cancer incidence compared with IL-N. Elevated risk remained in IL-S after adjusting for relevant factors such as smoking and socioeconomic deprivation (IRR = 1.14; 95% CI, 1.04-1.26). CONCLUSIONS: Socioeconomic deprivation, health behaviors, and lung cancer incidence varied across rural regions. Our findings underscore the importance of identifying cancer risk heterogeneity, even within a state, to effectively target risk factor reduction and cancer control interventions.

Impact of county rurality and urologist density on urological cancer mortality in illinois.

PURPOSE: The urology work force is contracting at a time when service demand is increasing due to demographic changes, especially in rural areas. We investigated the impact of rural status and urologist density on kidney and renal pelvis, bladder and prostate cancer mortality at the county level in Illinois. MATERIALS AND METHODS: We stratified the 102 Illinois counties by 2003 RUCCs as urban (36, RUCCs 1 to 3) and rural (66, RUCCs 4 to 9). Area Health Resource Files were used for county demographic data and urologist density. County level age adjusted mortality rates from 1990 to 2010 were derived from National Center for Health Statistics data using SEER*Stat. We examined the associations of urological cancer mortality rates with rural status and urologist density. RESULTS: Average urologist density significantly differed between rural and urban counties (1.9 vs 3.4/100,000 population, p < 0.01). The kidney and renal pelvis cancer mortality rate in rural counties was higher than in urban counties while that of prostate cancer was lower (4.9 vs 4.3 and 28.7 vs 32.2/100,000 population, respectively, each p < 0.01). Urologist density correlated with the mortality rate of kidney and renal pelvis cancer (Pearson coefficient -0.33, p < 0.01) but not with the bladder or prostate cancer mortality rate. Multiple regression analysis revealed that rurality and lower urologist density (p = 0.01 and < 0.05) were significantly associated with higher kidney and renal pelvis cancer mortality. CONCLUSIONS: Rural residence and low urologist density were associated with increased kidney and renal pelvis cancer mortality on the county level in Illinois. Further expansion and testing of evidence-based telemedicine is warranted because remote technical consultation is now technologically feasible, effective, inexpensive and satisfactory to patients.