Rural-dwelling Adults Research Articles

Exercise Telehealth in Rural-Dwelling Adults with Subjective Cognitive Decline: The MN RIDE Pilot Study

ABSTRACT Background The subjective cognitive decline (SCD) state offers a therapeutic window where interventions, such as aerobic exercise (AEx), have strong potential to delay the progression to Alzheimer’s disease and related dementias (ADRDs). Rural communities have greater barriers in participating in exercise and are at a higher risk of developing ADRDs than urban dwellers. The purpose of this pilot study was to evaluate the preliminary effectiveness of a synchronous AEx telerehabilitation program in persons with SCD living in rural areas. Methods The MN RIDE Study used a single-group, pretest-posttest design. All AEx sessions were supervised remotely via smart devices and Zoom by clinical exercise physiologists. The moderate-intensity AEx program was performed 3 times per week for 3 months (36 sessions). Outcomes assessed in participants’ places of residence included ADRD risk factors (depression [Geriatric Depression Scale]), cardiorespiratory fitness (1-min heart rate recovery from YMCA Step Test), and quality of life (WHOQOL). Paired t tests were performed, and effect sizes (Cohen’s d) were determined. Results The average age of the study sample (n = 9) was 57.4 ± 7.2 years (average age of SCD onset of 53.4 ± 7.5 years) with 14.0 ± 5.6 years of education; 78% of the participants were female. Moderate effect sizes were observed for the Geriatric Depression Scale (d = −0.65 [−1.39, 0.14]). Large effect sizes were observed for cardiorespiratory fitness (d = 0.73 [−15.49, 41.99]) and domain 1 on WHOQOL (d = 1.35 [−0.44, 1.82]). Conclusions Our study provides preliminary effectiveness and effect sizes regarding AEx telerehabilitation in persons with SCD living in underserved rural communities.

“It frees your body from that pain thought”: A mixed-methods exploration of patterns, contexts, and experiences of cannabis use for pain in rural communities

U.S. adults increasingly report using cannabis to manage chronic pain and rural areas have inadequate comprehensive pain management. Using mixed methods, we aimed to understand how and why some rural adults use cannabis for pain, including within the context of co-use with opioids. Participants (N = 14, Oklahoma) were rural-dwelling adults who used tobacco and ≥1 other substance, including cannabis and opioids, ≥3 days per week. Participants completed 14 days of ecological momentary assessment (EMA) regarding substance use and subsequent in-depth interviews discussing maps of their substance use reports. Half (7/14) described cannabis use for chronic pain, and most of these (85%) reported use on ≥75% of EMA days. The most frequently reported cannabis use motive was therapeutic/medicinal (90% of use reports). Most reports were of combusted cannabis (88% of use reports) at home (99% of use reports). Same-day use of cannabis and opioids was relatively common (45% of daily surveys), but seemingly not within close temporal proximity. Interview narratives characterized cannabis as modifying pain-adjacent factors (eg, thoughts), not eliminating pain itself. They recounted using a repertoire of substances to manage different pain dimensions (eg, intensity, quality) and balance perceived trade-offs of different substances. Participants described high medical cannabis access, low pain specialist access, and most physicians as unwilling to discuss cannabis for pain. The findings suggest that rural-dwelling patients could benefit from increased access to comprehensive pain management, having cannabis addressed within pain management provider discussions, and that risks and benefits of cannabis use for pain must be better established. PerspectiveThis study used a geographically explicit EMA mixed method to gather rich, intensive pilot data on cannabis use and co-use for chronic pain in rural Oklahoma. It provides unique insights to inform future research on cannabis use among a vulnerable and understudied subgroup of adults with pain—rural residents.

Weight management in rural health clinics: Results from the randomized midwest diet and exercise trial.

Rural living adults have higher rates of obesity compared with their urban counterparts and less access to weight management programs. Previous research studies have demonstrated clinically relevant weight loss in rural living adults who complete weight management programs delivered by university affiliated interventionists. However, this approach limits the potential reach, adoption, implementation, and maintenance of weight management programs for rural residents. Weight management delivered through rural health clinics by non-physician clinic associated staff, for example, nurses, registered dieticians, allied health professionals, etc. has the potential to improve access to weight management for rural living adults. This trial compared the effectiveness of a 6-month multicomponent weight management intervention for rural living adults delivered using group phone calls (GP), individual phone calls (IP) or an enhanced usual care control (EUC) by rural clinic associated staff trained by our research team. Rural living adults with overweight/obesity (n=187, age∼50years 82% female, body mass index ∼35kg/m2) were randomized (2:2:1) to 1 of 3 intervention arms: GP, which included weekly∼45min sessions with 7-14 participants (n=71), IP, which included weekly∼15min individual sessions (n=80), or EUC, which included one-45min in-person session at baseline. Weight loss at 6months was clinically relevant, that is, ≥5% in the GP (-11.4kg, 11.7%) and the IP arms (-9.1kg, 9.2%) but not in the EUC arm (-2.6%, -2.5% kg). Specifically, 6month weight loss was significantly greater in the IP versus EUC arms (-6.5kg. p≤0.025) but did not differ between the GP and IP arms (-2.4kg, p>0.025). The per participant cost per kg. weight loss for implementing the intervention was $93 and $60 for the IP and GP arms, respectively. Weight management delivered by interventionists associated with rural health clinics using both group and IP calls results in clinically relevant 6months weight loss in rural dwelling adults with overweight/obesity with the group format offering the most cost-effective strategy. Clinical trial registration: ClinicalTrials.gov (NCT02932748).

Co-design of a personalised digital intervention to improve vegetable intake in adults living in Australian rural communities

Diets low in vegetables are a main contributor to the health burden experienced by Australians living in rural communities. Given the ubiquity of smartphones and access to the Internet, digital interventions may offer an accessible delivery model for a dietary intervention in rural communities. However, no digital interventions to address low vegetable intake have been co-designed with adults living in rural areas(1). This research aims to describe the co-design of a digital intervention to improve vegetable intake with rural community members and research partners. Active participants in the co-design process were adults ≥18 years living in three rural Australian communities (total n = 57) and research partners (n = 4) representing three local rural governments and one peak non-government health organisation. An iterative co-design process(2) was undertaken to understand the needs (pre-design phase) and ideas (generative phase) of the target population through eight online workshops and a 21-item online community survey between July and December 2021. Prioritisation methods were used to help workshop participants identify the ‘Must-have, Should-have, Could-have, and Won’t-have or will not have right now’ (MoSCoW) features and functions of the digital intervention. Workshops were transcribed and inductively analysed using NVivo. Convergent and divergent themes were identified between the workshops and community survey to identify how to implement the digital intervention in the community. Consensus was reached on a concept for a digital intervention that addressed individual and food environment barriers to vegetable intake, specific to rural communities. Implementation recommendations centred on i) food literacy approaches to improve skills via access to vegetable-rich recipes and healthy eating resources, ii) access to personalisation options and behaviour change support, and iii) improving the community food environment by providing information on and access to local food initiatives. Rural-dwelling adults expressed preferences for personalised intervention features that can enhance food literacy and engagement with community food environments. This co-design process will inform the development of a prototype (evaluation phase) and feasibility testing (post-design phase) of this intervention. The resulting intervention is anticipated to reduce barriers and support enablers, across individual and community levels, to facilitate higher consumption of vegetables among rural Australians. These outcomes have the potential to contribute to improved wellbeing in the short term and reduced chronic disease risk in the long term, decreasing public health inequities.

Abstract P373: Psychosocial Risk and Resilience Profile in Rural Alabama: A Preliminary Analysis of Risk Underlying Rural Areas Longitudinal (RURAL) Study

Background: Given the disproportionate burden of cardiovascular disease risk and outcomes, there is an urgent need to understand the psychosocial drivers of these inequities. We characterized the psychosocial risk and resilience profiles of a cohort of rural-dwelling adults in the southeast U.S. Methods: This preliminary analysis includes 765 participants with complete covariate data (mean age 47.9 (SD=10.9), 70.7% self-reporting as women, 77.9% Black individuals, 41.4% with annual household income below $15,000; 43.7% possessing a high school diploma/GED or lower) residing in two rural counties in Alabama, part of the larger RURAL study. We evaluated participants across six crucial psychosocial domains: financial strain (continuous), financial adjustments (categorized as 0, 1-3, 4+), housing stability (tertiles), childhood adversity (including general, physical, and emotional trauma experienced before 18 years, categorized into tertiles), depression (measured using CES-D 16; yes/no), and resilience (measured using CD-RISC, categorized into tertiles). We examined the distribution of study outcomes and conducted race and sex-based comparisons. Results: Resilience was high overall and did not vary significantly by race or sex. Significant racial disparities were observed, with Black participants experiencing higher financial strain (mean: 2.84 Black vs. 2.34 White), housing instability (30.1% Black vs. 11.9% White), and elevated depressive symptoms (35.2% Black vs. 25.3% White). Conversely, White participants reported greater general trauma and depression (highest tertile: 17.8% Black, 23.8 % White for general trauma; 64.3% Black vs. 73.8% White for depression). Sex-based differences were statistically insignificant across most psychosocial factors, except for financial adjustments (highest tertile: 27.7% men vs. 36.0% women) and physical trauma (38.0% men vs. 22.0% women). When considering the intersection of race and sex, Black men had the highest prevalence of housing instability (highest tertile: 35.2% Black men, 27.8% Black women, 6.8% White men, 15.8% White women), and elevated depressive symptoms (35.8% Black men, 35% Black women, 15.3 % White men, 31.6% White women). White men had the highest prevalence of physical trauma (highest tertile: 35.8% Black men, 21.3% Black women, 44.1% White men, 25.3% White women), and White women had the highest prevalence of financial adjustments (highest tertile: 30.3% Black men, 33.9% Black women, 20.3% White men, 46.3% White women). Conclusion: Our preliminary analysis of the RURAL study underscores substantial psychosocial adversity in these Southern rural communities. Future investigations should explore the relationship between these psychosocial factors and CVD risk to help identify potential intervention targets to improve cardiovascular health in rural communities.

The MN RIDE pilot: feasibility of a synchronous, remotely delivered, aerobic exercise training program for rural-dwelling adults with subjective cognitive decline

The MN RIDE pilot: feasibility of a synchronous, remotely delivered, aerobic exercise training program for rural-dwelling adults with subjective cognitive decline

Mobile Health Application and Hypertension Management in Rural, Middle-Aged Adults: A Quality Improvement Project.

Over 29% of the adult population in the United States are diagnosed with hypertension, and rates are significantly higher in those adults who live in rural areas. Hypertension is recognized as the most prevalent comorbidity and modifiable risk factor leading to premature death. The purpose of this quality improvement project was to determine if using a mobile phone-based health application called Medisafe could enhance medication adherence and improve blood pressure control in rural-dwelling adults. A small group (N = 14) of middle-aged (45-64 years old) patients with hypertension were recruited to download the free Medisafe phone-based health application. Patients utilized the Medisafe application between their initial visit and a 4- to 6-week follow-up. At the follow-up visit, 64% (n = 9) of participants improved their level of hypertension control by blood pressure classification and improved their scores on the medication adherence questionnaire. The findings from this quality improvement project suggest the Medisafe application is useful to enhance medication adherence and blood pressure control. Future research and quality improvement initiatives are necessary to determine the broader efficacy of phone-based health applications in the rural adult population.

Association of Accelerometer-Measured Sedentary Behavior Patterns With Nonalcoholic Fatty Liver Disease Among Older Adults: The MIND-China Study.

The relationships between sedentary behavior patterns and nonalcoholic fatty liver disease (NAFLD) in older adults are not well investigated. This population-based study included 1,899 rural-dwelling adults (aged 60 years or older). We assessed sedentary parameters with ActiGraph and defined NAFLD using ultrasonography. Long total and prolonged sedentary time were associated with increased likelihoods of NAFLD, whereas engaging more breaks per sedentary hour and reallocating sedentary time to light-intensity physical activity were associated with reduced likelihoods of NAFLD (P linear <0.05). Shorter sedentary time, engaging more frequent breaks in sedentary behavior, and replacing sedentary time with physical activity are associated with reduced likelihoods of NAFLD in older adults.

Effect of a Digital Literacy Program on Older Adults' Digital Social Behavior: A Quasi-Experimental Study.

In South Korea, digital literacy education programs are expected to help its older population participate in online welfare services to increase their social support, self-esteem and well-being. This quasi-experimental study assesses the effects of digital literacy education on digital device usage among rural-dwelling adults aged 65 and above and evaluates the positive effects of digital literacy education on depression, happiness, quality of life, self-efficacy and cognitive function. A digital literacy education program and a customized questionnaire survey were conducted to evaluate smartphone use competency and the program’s effects, respectively. We also conducted a chi-square test, paired t-test and difference-in-differences regression analysis. The experimental group showed a significant increase in smartphone usage and video recording capacity than the control group. The happiness and cognitive function scores for dementia screening increased significantly by a mean of 3.7 and 1.1 points, respectively, after digital literacy education. Cognitive function increased significantly by 1.305 points in the experimental group compared to the control group (β = 1.305, p = 0.05 *). Digital literacy education for older adults in rural areas greatly increased smartphone use, video recording capacity, happiness and cognitive function. Based on these findings, it is recommended that the government should implement digital literacy education for older adults in rural areas to increase their happiness and cognitive function.

Impacts of the COVID-19 Pandemic on a Community-Based, Palliative Care Lay Advisor Project for Latinos with Cancer

The COVID-19 pandemic posed challenges to a community-based participatory research (CBPR) project for rural-dwelling adults with cancer in eastern North Carolina. This project trained Latino community leaders as palliative care lay advisors (PCLAs) to deliver information on cancer symptom management and advance care planning (ACP). Pandemic impacts were assessed using data from team meetings and fieldnotes, journal memos, online booster sessions, participant encounter forms and digital correspondence. Three key results were: 1) the disproportionate effects of COVID -19 on PCLAs and their communities; 2) the need for a major study redesign that extended the recruitment region and changed the mode of intervention delivery; and 3) the adoption of new channels of communication. Online discussions and in-person meetings with PCLAs sustained engagement, resulting in a two-year, 73 percent retention rate, and addressed community concerns about COVID-19. Applied outcomes included the selection by the regional cancer center of a 2022 goal to improve cultural care for Latinos and the empowerment of PCLAs as community advocates. The challenges created by COVID-19 were met by the study team’s ongoing commitment to CBPR principles, flexible adaptations to a changing environment, and strong relationships forged with community members and advocacy groups.

Associations of residential greenness with obesity and BMI level among Chinese rural population: findings from the Henan Rural Cohort Study.

In recent years, increasing evidence supports the notion that obesity risk is affected by residential greenness. However, limited studies have been established in low- and middle-income countries, especially in China. The study aimed to evaluate the associations of residential greenness with obesity and body mass index (BMI) level in Chinese rural-dwelling adults. A total of 39,259 adults from the Henan Rural Cohort Study (HRCS) were included in the analyses. According to the guideline for prevention and control of overweight and obesity in Chinese adults, obesity was defined as BMI ≥ 28kg/m2. Residential greenness was measured by satellite-based normalized difference vegetation index (NDVI) and enhanced vegetation index (EVI). Generalized linear mixed models were used to study the associations between exposure to residential greenness with obesity and BMI level. Higher residential greenness was significantly correlated with lower odds of obesity and BMI level. For example, in the full-adjusted analyses, an interquartile range (IQR) increase in EVI500-m was linked with reduced odds of obesity (OR = 0.77, 95%CI 0.72-0.82) and BMI level (β = - 0.41kg/m2, 95%CI - 0.48 to - 0.33kg/m2). Mediation analyses showed air pollution and physical activity could be potential mediators in these associations. Besides, we found that the association of NDVI500-m with BMI was stronger in females and low-income populations. Higher residential greenness was associated with a lower prevalence of obesity and BMI level, particularly among females and the low-income population. These relationships were partially mediated by reducing air pollution and increasing physical activity.

Selecting a theoretical framework for chronic cardiovascular disease self-management among rural dwelling adults

A paucity of research has examined the factors and perceptions of self-management among individuals living rurally with chronic cardiovascular disease (CCVD). Exploration of this population is prudent as CCVD continues to be the leading cause of mortality within the United States (US). As the US population ages, increased rates of CCVD and the process of managing the disease will continue to challenge patients and the health care system. Rural dwelling adults are faced with additional complexities to manage a chronic disease, resulting in higher rates of chronic disease as compared to urban dwellers. It is essential for nurses working with adults living with CCVD in rural areas to promote self-management strategies derived from a theoretical perspective. The purpose of this paper is to examine theories and models that facilitate self-management of CCVD among rural dwelling adults. Three established self-management theories and models from psychology and public health were evaluated using Walker and Avant's framework for theory analysis. Social cognitive theory was selected as a best fit for self-management of CCVD among rural dwelling adults, due to the symbiosis of chronic disease, and applicability of ruralness within the triadic reciprocal causation of person-behavior-environment of the model.

Understanding Racial and Rural Disparities in the Relationship between Social Isolation and Social Technology Use

Social isolation is characterized by lack of social contacts and high degrees of loneliness. Feelings of loneliness and social isolation are linked to declines in cognitive functioning and increased risk of dementia. Previous research suggests that loneliness is more prevalent among Black and rural older adults compared to White and urban-dwelling older adults. Given these disparities, it is important to identify methods that reduce social isolation and loneliness among this population. Social technology, such as Facebook and Skype, is one possible way to connect with others. This study uses the Health and Retirement Study (HRS) dataset to examine racial and rural disparities in the relationship between social technology use and social isolation, loneliness, and social support among individuals age 50 and older. The overarching hypotheses are that (1) rural-dwelling older adults and older Blacks will report less social technology use compared to urban-dwelling and older White adults, and (2) there will be a negative relationship between loneliness and social technology use, and (3) a positive relationship between perceived positive social support and social technology use. Racial or rural disparities in these latter potential relationships are exploratory. Multiple linear regression analysis will be performed to assess these relationships. Preliminary correlational results indicate that, consistent with prior work, greater use of social technology was associated with higher social support (N=6,029; r=.29, p<.001). However, contrary to our hypothesis, greater self-reported loneliness was associated with greater social technology (r=.09, p<.001). Examination of potential racial and rural disparities in these relationships are currently underway.

Using Clinical Trials as Agents of Transformation in Populations Burdened by Disparities

Older adults from racial/ethnic backgrounds as well as those from rural areas experience a disproportionate burden of physical and mental health risk factors. Given the prevalence of comorbid physical and mental health conditions in later life, the inadequacies of current treatment approaches for averting years living with disability, the disparities in access to the health care delivery system (including mental health care), and the workforce shortages to meet the mental and physical health needs of racial/ethnic and rural populations, development and testing of innovative strategies to address these disparities are of great public health significance and have the potential to change practice. This session will illustrate how four different interventions are being used to address mental and physical health needs in Latino and rural-dwelling older adults with the goal of reducing and ultimately eliminating disparities in these populations. Particular attention will be paid to the use of non-traditional interventions (e.g. social support, health promotion, technology). Results of clinical research studies will be presented alongside clinical case presentations. This integrated focus highlights the importance of adapting research interventions to real-world clinical settings.

Engaging Rural and Racial-Ethnic Populations in Gerontological Research

Older adults from racial/ethnic populations, as well as rural-dwelling older adults, are often at heightened risk for experiencing health disparities. Reasons for these disparities may include access issues, language barriers, distrust, lack of awareness, and of culturally appropriate materials. Racial/ethnic populations and rural-dwelling populations are also less likely to be included in research to help minimize the impact of these disparities. Shifting from reducing disparities to eliminating disparities will require attentiveness to designing programs and research that focus on increasing representation of racial/ethnic groups in research, integrating diverse populations (particularly rural and other marginalized groups) into the development of ideas and projects, and finally a commitment to culturally appropriate and inclusive approaches to research and education. Applying these strategies can provide guidance on how to best facilitate inclusive and equitable research, collaborative partnerships, and equitable healthcare for everyone, especially those from populations often underrepresented.

Transforming Aging: Increased Access to Care Minimizes Rural and Urban Differences in Cognitive Change

Rural-urban disparities in cognitive health outcomes, such as greater prevalence of cognitive decline among rural-dwelling older adults, have been linked to inequity in access to care. However, few studies have demonstrated whether longitudinal increased access to care may mitigate such disparities. This paper presents data from ongoing systematically collected behavioral health data on new and returning patients at an interdisciplinary geriatrics clinic at the University of Alabama Medical Center. The aim of this study was to determine baseline predictors of cognitive change across three annual visits (n = 42, mean age of 75.63 years (SD = 9.15)). Adjusting for baseline cognitive status, baseline subjective health literacy, and baseline depression and anxiety, results from a univariate ANCOVA showed that age at first visit (B = -.024, 95% CI [-.041, -.008], t(35) = -2.990, p = .005) and rural-urban status (B = .555, 95% CI [.123, .988], t(35) = 2.608, p = .013) predicted cognitive change at timepoint three (T3). Specifically, individuals from rural areas were less likely to experience cognitive decline and scored .555 points better than individuals from urban areas on cognitive screeners at T3 compared with baseline cognitive status. These results suggest that increased access to and utilization of care may ameliorate traditional disparate rates of cognitive decline between rural- and urban-dwelling older adults. Moreover, behavioral health screenings in primary geriatrics clinic care may help identify patient cognitive needs and facilitate integrated care through combined medical, pharmacological, and behavioral interventions to promote positive cognitive health outcomes.

Impact of whey protein supplementation in a weight-loss intervention in rural dwelling adults: A feasibility study

Weight loss in older adults enhances physical function, but may lead to sarcopenia and osteoporosis. Whey protein is a low cost rich source of essential amino acids, may improve physical function. We evaluated the feasibility and acceptability of consuming whey protein in the context of a weight-loss intervention in older adults with obesity. A 12-week pilot feasibility, non-randomized weight loss study of 28 older adults was conducted, consisting of individualized, weekly dietitian visits with twice weekly physical therapist-led group strengthening classes. Half consumed whey protein, three times weekly, following exercise. Preliminary efficacy measures of body composition, sit-to-stand, 6-min walk and grip strength and subjective measures of self-reported health and function were also evaluated. Of the 37 enrolled, 28 completed the study (50% in the protein group). Attendance rates for protein vs. non-protein groups were 89.9±11.1% vs. 95.6±3.4% (p=0.08). Protein consumption was high in those attending classes (90.3%) as was compliance at home (82.6%). Whey was pleasant (67.3±22.1, range 30-100, above average), had little aftertaste, and was neither salty or sticky. All were compliant (0.64±0.84, range 0-5, low=higher compliance). Both groups lost significant weight (protein vs. no protein,-3.45±2.86 vs.-5.79±3.08, p=0.47); Sit-to-stand, 6-min walk, and gait speed were no different, grip strength was improved in the protein compared to the non-protein group (-2.63kg vs. 4.29kg; p<0.001). Our results suggest that whey protein is a low-cost and readily available nutritional supplement that can be integrated into a weight loss intervention.

Is residential greenness associated with dyslipidemia and lipid levels in Chinese rural-dwelling adults? The Henan rural cohort study.

Scarce epidemiologic research examined the associations between residential greenness and dyslipidemia or lipid levels in low/middle-income countries. Baseline statistics (2015-2017) of 39,259 rural-dwelling adults were obtained from a Chinese longitudinal study. The blood lipid level was measured utilizing an enzymatic assay method. According to the 2016 Chinese guidelines on dyslipidemia (revision), patients with dyslipidemia were defined. Participants' exposure to residential greenness was characterized by the satellite-based normalized difference vegetation index (NDVI). Mixed effects logistic regression and mixed effects linear regression were performed to assess the associations of residential greenness with dyslipidemia and lipid levels. The median (interquartile range, IQR) of 3-year average NDVI1000-m was 0.521 (0.089) units. Each IQR increase in NDVI1000-m was significantly linked with increased odds of hyperbetalipoproteinemia (OR = 1.33, 95%CI 1.21-1.46). The same increment in NDVI1000-m was associated with lower total cholesterol (TC) levels and increased low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) levels. For instance, the %changes in HDL-C levels was 0.71% (95%CI 0.17%-1.26%). The above relationships were partially mediated by reducing air pollution and lowering body mass index (BMI). Interaction effect analysis observed the greenness-lipid association was stronger in males than females (i.e., NDVI1000-m-TC association). Long-term exposure to residential greenness was associated with odds of dyslipidemia and lipid levels in Chinese rural-dwelling adults, particularly among males. Considering the cross-sectional study design, more longitudinal studies are needed to identify the causal associations.

Yoga Intervention for Fall Prevention in Rural-Dwelling Seniors

Abstract Date Presented 04/200/21 Rural-dwelling older adults experience health care disparities and limited access to physical activity programming. The purpose of this study was to examine fall-related outcomes following a 12-week yoga intervention designed for rural older adults. Significant improvements in the Canadian Occupational Performance Measure and MiniBESTest were observed, suggesting that yoga could be an appropriate and accessible strategy for addressing fall prevention and occupational performance in rural-dwelling older adults. Primary Author and Speaker: Alicia Oestreich Additional Authors and Speakers: Julia Bieber, Christine Auriemma, Casey Flanigan, Hannah Frolli, Maria McGloin, Meghan O'Brien, Emma Oliver, and Tara Schorr

Barriers to care in urban and rural dwelling adults with congenital heart disease

Adults with congenital heart disease (CHD) face a unique set of medical, psychological, and social challenges, and access to specialised adult congenital heart disease care has been associated with improved outcomes. Rural adults with CHD may represent a uniquely disadvantaged group given additional challenges when accessing specialised care. The aim of this study was to investigate the challenges faced by adults with CHD in accessing outpatient cardiac care, with a specific focus on understanding differences between urban- and rural-dwelling patients. This cross-sectional, survey-based study took place in the adult congenital heart disease clinic at an urban academic medical center. Additional medical information was abstracted in a retrospective manner from the electronic health record. In addition to descriptive statistics, t-tests and Chi-square tests were performed to investigate differences between urban and rural dwelling patients. A total of 100 patients participated in the study (mean age 40±13 years, 60% female, 18% rural dwelling). Across the total sample, the median driving distance to clinic was 20 miles (interquartile range 12-77); it was 15 miles for urban dwellers and 77 miles for rural dwelling patients (p < 0.001). The most commonly identified barriers to cardiac clinic visits were financial losses related to taking time off from work (39%), distance of clinic from home (33%), and weather (33%). Compared to urban dwelling patients, on average those who were rural dwelling had a lower level of education (p = 0.04), more difficulty paying insurance premiums (p < 0.001) and copays (p = 0.005), and were more likely to identify the distance from clinic (p = 0.05) and having to go into the city (p = 0.02) as barriers to clinic appointments. The financial impact and distance to clinic were the most commonly identified barriers to outpatient cardiac care in this cohort of adults with CHD. These barriers, along with difficulty paying insurance premiums, are more common in rural dwelling patients. Initiatives such as telemedicine visits or providing financial subsidies for travel and treatment could help to expand specialty adult congenital heart disease care and better serve this growing patient population.