Rural Health Policy Research Articles

Does the integration of urban and rural health insurance influence the functional limitations of the middle-aged and elderly in rural China?

In January 2016, the Chinese government integrated the two systems of urban resident basic medical insurance and new rural cooperative medical system to establish a unified Urban and Rural Resident Medical Insurance. The integration of medical insurance is purported to enhance access for the rural population; however, a dearth of literature exists regarding its effect on functional impairment among middle-aged and elderly residing in rural areas. This study aims to evaluate the impact of urban-rural health insurance integration on functional limitation among middle-aged and elderly individuals in rural China. A longitudinal survey was conducted among 7855 middle-aged and elderly individuals in rural China. Using a nonequivalent control group pretest-posttest design, we exploit these policy changes to evaluate their impact on middle-aged and elderly individuals’ functional limitation. The results showed that the integration of urban and rural health insurance systems was significantly associated with reduced functional limitation (Odds ratio .742; 95%CI 0.603, 0.914) among middle-aged and elderly individuals in rural China. Our findings also indicate that prevalent behaviors such as tobacco use, and alcohol consumption may exacerbate functional limitation among middle-aged and elderly individuals. These findings suggest that the integration of urban and rural health insurance systems can have a positive impact on the functional limitation of middle-aged and elderly individuals in rural China and could be an important factor in improving the health and well-being of middle-aged and elderly individuals in rural areas.

Unlocking Opportunities for Migrant Workers in China: Analyzing the Impact of Health Insurance on Hukou Switching Intentions

The Chinese urban–rural binary health insurance structure has contributed to a significant urban–rural segmentation and regional fragmentation, which will affect labor mobilization and urbanization. The purpose of this research is to study whether and how urban–rural binary health insurance impacts the intentions of migrant workers to switch between rural and urban hukou. Pooled data were drawn from China Migrants Dynamic Survey, collected by the National Health Commission of China. The study applied the instrument variable model due to the existence of the endogeneity; and the IVprobit model to conduct the empirical analysis. Our findings are as follows: (1) the urban–rural binary health insurance affects migrant workers’ intentions to switch to urban hukou significantly. (2) The negative impact of originally rural health insurance on migrant workers’ intention of switching to urban hukou is relatively large for low-education-level migrant workers. (3) Compared with new generation of migrant workers, old migrant workers have higher health insurance dependency levels. Finally, our research suggested several policy implications, such as accelerating the establishment of a unified urban–rural health insurance system, increasing the urban health insurance participation rate of migrant workers in their working cities, and including migrant workers in the scope of equal access to urban public services, etc. All the policy suggestions are essential in order to accelerate the citizenization of migrant workers, improve the quality of urbanization, and promote the construction of a unified national labor market.

The efficient moral hazard effect of health insurance: Evidence from the consolidation of urban and rural resident health insurance in China

Ex post moral hazard, the additional healthcare utilization induced by health insurance, can be decomposed into an efficient portion generated by the income effect and an inefficient portion caused by the substitution effect, which has been discussed theoretically, but few studies have provided evidence of the efficient moral hazard. In 2016, the Chinese government launched the consolidation of urban and rural resident health insurance at the national level. After the consolidation, insurance benefits for nearly 800 million rural residents got improved. This paper uses a nationally-representative sample of 30,972 individuals from the China Health and Retirement Longitudinal Study (2011–2018) and adopts a 2-step empirical approach with the difference-in-differences method and the fuzzy regression discontinuity design to estimate the efficient moral hazard in the consolidation among rural residents. We find that the price shock contained in the consolidation increases inpatient care utilization, and the corresponding price elasticity is between −0.68 and −0.62. Further analysis shows that the efficient moral hazard resulting in welfare gains accounts for 43.33%–66.36% of the additional healthcare utilization. These findings highlight the necessity of evaluating the efficient moral hazard when analyzing the cost-benefit of health insurance reform.

COVID-19 Vaccination Coverage among 42,565 Adults Amid the Spread of Omicron Variant in Beijing, China.

Vaccines against coronavirus disease 2019 (COVID-19) have been in use for over two years, but studies that reflect real-world vaccination coverage and demographic determinants are lacking. Using a multistage stratified random cluster sampling method, we planned to directly explore vaccination coverage and the demographic determinants of different doses of COVID-19 vaccines in Beijing, especially in older populations. All 348 community health service centers in 16 districts were involved. We performed multivariable logistic regression analyses to identify demographic determinants of different coverage rates via adjusted odds ratios (aORs) and 95% CIs. Of the 42,565 eligible participants, the total vaccination coverage rates for ≥1 dose, ≥2 doses, ≥3 doses, and 4 doses were 93.3%, 91.6%, 84.9%, and 13.0%, respectively, but decreased to 88.1%, 85.1%, 76.2%, and 3.8% in the older population. Among all participants, younger (aOR = 1.77, 95% CI: 1.60-1.95), male (aOR = 1.15, 95% CI: 1.06-1.23), and better-educated residents (high school and technical secondary school aOR = 1.58, 95% CI: 1.43-1.74; bachelor's degree aOR = 1.53, 95% CI: 1.37-1.70) were more likely to be fully vaccinated. People who lived in rural areas (aOR = 1.45, 95% CI: 1.31-1.60) and held the new rural cooperative health insurance (aOR = 1.37, 95% CI: 1.20-1.57) established a higher rate of full vaccination coverage. No history of chronic disease was positively associated with a higher coverage rate (aOR = 1.81, 95% CI: 1.66-1.97). Occupation also affected vaccination coverage. Demographic factors influencing the rate of vaccination with at least one or three doses were consistent with the results above. Results remained robust in a sensitivity analysis. Given the highly transmissible variants and declining antibody titers, accelerating the promotion of booster vaccination coverage, especially in high-risk groups such as the elderly, is a top priority. For all vaccine-preventable diseases, rapidly clarifying vaccine-hesitant populations, clearing barriers, and establishing a better immune barrier can effectively safeguard people's lives and property and coordinate economic development with epidemic prevention and control.

Twenty-five years of the Medicare Rural Hospital Flexibility Program: The past as prologue.

The Medicare Rural Hospital Flexibility (Flex) Program and the Critical Access Hospital (CAH) provider type are now 25 years old. Since the inception of the program, the needs of CAHs have evolved greatly. This article describes the history of the limited-service hospital model that led to the creation of CAHs, the evolution and impact of the Flex Program on CAHs, and the trends likely to impact CAHs and rural healthcare in the future. It concludes with recommendations to address these future needs. This review of the 25-year history of the Flex Program and CAHs is based on a detailed analysis of the literature on the limited-service hospital model and CAHs, the evaluation reports of the Flex Tracking and Flex Monitoring Teams, and the author's 25-year history with the program. The Flex Program has made important contributions to the viability of rural hospitals through the conversion of 1,360 CAHs. The program has encouraged attention on CAH quality of care and the role of CAHs in addressing the population health needs of their communities. It has further encouraged the development of a robust rural health policy and advocacy infrastructure that has heightened attention on the needs of rural providers and communities. The needs of CAHs and rural delivery systems have evolved greatly since the implementation of the Flex Program. The 25th anniversary of the program is an ideal time to re-evaluate and update the program to support CAHs in adapting to the fast-changing healthcare environment.

Can rural health insurance coverage improve educational attainment? Evidence from new cooperative medical scheme in China

This paper bridges health policy with education outcomes through eight waves of a nationally-representative health survey in China. We construct an index of health poverty with CHNS (1991–2011) data, and find health poverty in period (t-1) is significantly detrimental to education outcomes in period t. We further treat the expansion of New Cooperative Medical Scheme (NCMS) in rural China as a quasi-natural experiment and evaluate the effect of the publicly provided health insurance on education attainment. We find that NCMS participation can increase individual's schooling by 0.54, 0.75 and 0.83 years in east, central and west regions, respectively. The effect is larger for those at lower education levels, i.e. for individuals at 15% percentile schooling level, the schooling increases by 1.12, 1.43 and 1.72 years in the east, central and west. The effect is larger for women than men, for the unhealthy, risk-avoiding group relative to healthy group, and sustains longer in the central than other regions. Among different insurance clauses in NCMS, the outpatient medical service compensation generates stronger effect on education outcomes.

25 years of Flex: Supporting states in maintaining rural access to care.

The Medicare Rural Hospital Flexibility (Flex) Program secured access to care for rural communities, through the creation of the Critical Access Hospital provider type, keeping hospitals open in many communities where they may have otherwise closed. The Health Resources and Services Administration's Federal Office of Rural Health Policy has worked in partnership with hospitals, State Offices of Rural Health, State Flex Program coordinators, researchers, and rural hospital finance and quality experts to direct the Flex Program to ensure rural communities have access to high-quality care. This article outlines the history of the Flex Program, its program framework and state-level implementation, and the ways the program aligns with other federal programs with similar goals.

Factors associated with the uptake of biosimilars for breast cancer treatment from the perspectives of physicians and patients-Evidence from China.

Objective: To investigate the factors associated with the treatment of breast cancer with biosimilars from the perspectives of physicians and patients, and to generate evidence for promoting the uptake of biosimilars. Methods: This study targeted trastuzumab and its indicated human epidermal growth factor receptor 2 (HER2) positive breast cancer and included female HER2 positive breast cancer patients under treatment of trastuzumab at a provincial oncology medical center in southern China from 1 January 2021, to 31 December 2021. The study extracted patients' demographic, socioeconomic and clinical information and the basic information of their attending physicians from the hospital information system. We performed a bivariate multiple logistic regression analysis of predictive factors of the use of trastuzumab biosimilar. Results: A total of 446 patients (aged ranging between 26 and 74, 51.4 ± 9.06) were included in the analysis, and 19.1% chose biosimilar trastuzumab. Older patients, patients enrolled in the urban and rural resident health insurance program compared with those enrolled in the urban employee health insurance program, patients who initiated treatment after January 2021 when biosimilar entered clinical use compared with those who initiated treatment before, patients with female attending physicians, younger attending physicians and with chief attending physicians compared with deputy chief attending physicians were more likely to adopt biosimilar trastuzumab for treatment (p < 05). Controlling the other factors unchanged, when the patient's attending physician was deputy chief physician, increasing 1year age of the patient was associated with an increased probability of adopting biosimilar by .8% (dy/dx = .008, 95%CI: .002-.01, p = .01). When the patient was aged between 26 and 60, the probability of adopting biosimilar for the patient whose attending physician was a chief physician was higher than for those whose attending physician was a deputy chief physician, and the gap was the largest when the patient was at the age of 45 (dy/dx = .20, 95%CI: .13-.27, p < .01). Conclusion: The uptake rate of biosimilars is still low at its initial development stage in China. Educational policies and physicians making recommendations to the indicated patients at the initiation stage of treatment are helpful to avoid reduced willingness to switch to biosimilars due to non-clinical reasons. Patients with lower ability-to-pay will have better accessibility to biologic regimens through the uptake of biosimilars. Official guidelines and professional training are critical to enhancing physicians' willingness and confidence in adopting biosimilars.

Challenges of Rural Family Physician Policy in Iran.

As per the goals of the family physician program, it is essential to pay attention to the effectiveness and performance of FPP. Although the implementation of the FPP program is an important development in the discussion of rural health insurance and the provision of health services and referral systems in the country, the evidence suggests that by identifying challenges and taking appropriate action, this plan can be improved. This study aimed to investigate the challenges of rural Family Physician Policy (FPP) in northern Iran. This study comprised a mixed method. The former intended to identify the challenges of rural FFP using the narrative review method. To achieve a comprehensive list of challenges, a narrative review and content analysis were performed and semi-structured interviews were held with key stakeholders of FPP in the north of Iran, including physicians, managers, and policymakers. Identified challenges were categorized into eight categories including the weakness of the health insurance system, low comprehensiveness of executive guidelines, inappropriate recruitment and maintenance of human resources, weakness of cultural context, low efficacy of health information management system, poor educational effectiveness, inappropriate motivational mechanisms, and weakness of the referral system. As per the quantitative findings, "weakness of the referral system" and "inappropriate recruitment and maintenance of human resources" had the lowest and highest weaknesses, respectively. To address existing challenges in the rural FPP, a comprehensive plan of action should be developed with an emphasis on human resource management, health information management system, comprehensive rural health insurance, and legislation.

Age, race, insurance type, and digital divide index are associated with video visit completion for patients seen for oncologic care in a large hospital system during the COVID-19 pandemic.

The COVID-19 pandemic drove rapid adoption of telehealth across oncologic specialties. This revealed barriers to telehealth access and telehealth-related disparities. We explored disparities in telehealth access in patients with cancer accessing oncologic care. Data for all unique patient visits at a large academic medical center were acquired pre- and intra-pandemic (7/1/2019-12/31/2020), including visit type (in-person, video, audio only), age, race, ethnicity, rural/urban (per zip code by Federal Office of Rural Health Policy), distance from medical facility, insurance, and Digital Divide Index (DDI; incorporates technology/internet access, age, disability, and educational attainment metrics by geographic area). Pandemic phases were identified based on visit dynamics. Multivariable logistic regression models were used to examine associations of these variables with successful video visit completion. Data were available for 2,398,633 visits for 516,428 patients across all specialties. Among these, there were 253,880 visits from 62,172 patients seen in any oncology clinic. Dramatic increases in telehealth usage were seen during the pandemic (after 3/16/2020). In multivariable analyses, patient age [OR: 0.964, (95% CI 0.961, 0.966) P<0.0001], rural zip code [OR: 0.814 (95% CI 0.733, 0.904) P = 0.0001], Medicaid enrollment [OR: 0.464 (95% CI 0.410, 0.525) P<0.0001], Medicare enrollment [OR: 0.822 (95% CI 0.761, 0.888) P = 0.0053], higher DDI [OR: 0.903 (95% CI 0.877, 0.930) P<0.0001], distance from the facility [OR: 1.028 (95% CI 1.021, 1.035) P<0.0001], black race [OR: 0.663 (95% CI 0.584, 0.753) P<0.0001], and Asian race [OR: 1.229 (95% CI 1.022, 1.479) P<0.0001] were associated with video visit completion early in the pandemic. Factors related to video visit completion later in the pandemic and within sub-specialties of oncology were also explored. Patients from older age groups, those with minority backgrounds, and individuals from areas with less access to technology (high DDI) as well as those with Medicare or Medicaid insurance were less likely to use video visits. With greater experience through the pandemic, disparities were not mitigated. Further efforts are required to optimize telehealth to benefit all patients and avoid increasing disparities in care delivery.

Changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes in Beijing, China

BackgroundChina expanded health coverage to residents in informal economic sectors by the rural new cooperative medical scheme (NCMS) for rural population and urban resident basic medical insurance scheme (URBMI) for non-working urban residents. Fragmentation of resident social health insurance schemes exacerbated the health inequity and China started the integration of urban and rural resident medical insurance schemes since 2016. Beijing finished the insurance integration in 2017 and has been implementing a unified urban and rural resident basic medical insurance scheme (URRBMI) since the beginning of 2018. This study aims to examine changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes.MethodsWe used household survey data from Beijing Health Services Survey in 2013 and 2018. Respondents who were 15 or older and covered by URBMI, NCMS or URRBMI were included in this study. Our study finally included 8,554 individuals in 2013 and 6,973 individuals in 2018, about 70% of which were rural residents in each year. Descriptive analysis was used to compare the healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure between different groups. A series of two-part regression models were used to analyze the changes of healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure.ResultsFrom 2013 to 2018, urban–rural disparity in outpatient care utilization seemed widened because urban residents’ utilization of outpatient care increased 131% while rural residents’ utilization only increased 72%; both rural and urban residents’ spending on outpatient care increased about 50%. Utilization of inpatient care changed little and poor residents still used significantly less inpatient care compared with the rich residents. Poor residents still suffered heavily catastrophic health expenditures.ConclusionFrom 2013 to 2018, residents’ utilization of healthcare, especially outpatient care, increased in Beijing. Health insurance reforms increased residents’ utilization of healthcare but failed to reduce their healthcare financial burden, especially for poor people. Our study advocates more pro-poor insurance policies and more efforts on the efficiency of health system.

The challenge of ensuring elderly people can access their health insurance entitlements: a mixed methods study on the Republic of Srpska’s Protector of Patients’ Health Insurance Entitlements

IntroductionHealthcare utilisation requires knowing one’s entitlements and how to access them (navigation) and having access to grievance redressal when entitlements are denied. To ensure citizen access to and use of...

The effects of health insurance and physical exercise participation on life satisfaction of older people in China-Based on CHNS panel data from 2006 to 2015.

BackgroundIn China, the problem of aging population has become more and more serious. The factors influencing life satisfaction of older people are becoming a significant issue. This study explores the effects of health insurance and physical exercise on life satisfaction of older people in China.MethodThis study used an unbalanced panel dataset (n = 6,393, T = 4) of older adults aged 60–80 years from the 2006 to 2015 China Health and Nutrition Survey (CHNS). A panel ordered logistic regression model was developed to examine the effects of health insurance and physical exercise on older people' life satisfaction. Mediation tests were used to examine the mediating role of physical exercise in the effect of health insurance on life satisfaction of older people.ResultLife satisfaction of older people was positively associated with participation in health insurance (OR = 1.439) and physical exercise (OR = 1.033). Participation in government health insurance, urban employee health insurance (UEBMI), new rural cooperative health insurance (NRCMI), and other commercial health insurance all have positive effects on life satisfaction of older people. Physical exercise plays a masking role in the effect of health insurance on life satisfaction of older people.ConclusionParticipation in health insurance and physical exercise are important means to promote life satisfaction among older people. Physical exercise affects the impact of health insurance on older people's life satisfaction.

Heterogeneity of symptoms and functions among women receiving chemotherapy for breast cancer in China: A multicentre, cross-sectional study.

BackgroundCurrently, few studies have explored the heterogeneity of symptoms and functions in patients with breast cancer. This study aimed to identify the subgroups of symptoms and functions in women receiving chemotherapy for breast cancer and determine whether the subgroups differed in demographic and clinical characteristics.MethodsA cross-sectional multicenter survey involving five hospitals in Zhejiang, Shanghai, Shandong, and Guangxi provinces of Mainland China was implemented between August 2020 to December 2021. Participants completed questionnaires that included the PROMIS-57, PROMIS cognitive function short form, and demographic and clinical characteristics. Latent class analysis was performed, followed by chi-square test and analysis of variance. Subsequently, significant variables were included in multinomial logistic regression.ResultsA total of 1,180 patients were investigated, with an average age of 48.9 years. Three classes were identified: low symptom burdens and functions group (26.2%, Class 1), moderate symptom burdens and functions group (16.9%, Class 2), and low symptom burdens and high functions group (56.9%, Class 3). Compared with patients in Class 1 and 3, those in Class 2 consistently showed a higher tendency of having urban employee health insurance (odds ratio = 2.506, P < 0.05) and rural health insurance (odds ratio = 2.207, P < 0.05). Additionally, patients in Class 2 tended to be in their fourth cycle of chemotherapy. However, receiving chemotherapy and surgery increased the likelihood of belonging to Class 1.ConclusionsA high proportion of patients experienced varying degrees of symptom and function issues, suggesting that attention is warranted for women with breast cancer undergoing chemotherapy. Patients with the urban employee basic medical system, the new rural cooperative medical system and in the early stage of chemotherapy cycles were more likely to have symptom burdens. Middle-aged postmenopausal women reported varying degrees of cognitive issues. Additionally, surgery increased the presence of potential long-term effects in functional levels.

Gynecologic oncology patients living in rural areas less likely to utilize telemedicine services during the COVID-19 pandemic (054)

Objectives: The COVID-19 pandemic is an unprecedented event in the era of modern medicine and has resulted in a rapid shift in clinical care delivery to incorporate more telemedicine services. While there is a well-recognized need for the integration of telehealth into gynecologic oncology care, there are concerns about limitations of its use regarding access to and ability to use requisite technology. The purpose of this study was to characterize gynecologic oncology patients who utilized telemedicine as part of their cancer care during the pandemic in order to determine potential barriers and facilitators of telemedicine use.Methods: A single-institution retrospective chart review was performed of patients who participated in at least one telemedicine visit from March 1 to September 30, 2020, at an NCI-designated cancer center. Demographic factors were compared between telemedicine users and non-users using Fisher’s exact test for categorical values and the Wilcoxon rank-sum test for continuous variables.Results: A total of 2238 patients were seen during the study period. Of which, 193 patients participated in telemedicine visits, and 2045 patients did not participate in any telemedicine visit with gynecologic oncology providers (Table 1). The median age was 63 years in both groups, and 65% of users were older than 60 years versus 62% of non-users. There were no significant differences with respect to race and primary language; the majority were Caucasian and English-speakers. There was no difference in terms of insurance status; about 50% in each group were privately insured. Among the telemedicine users, 97% had private insurance or Medicaid/Medicare, compared to 93% of non-users. Among users, the median distance of the patient’s residence from the cancer center was 21 miles, with 36% living 50 miles or further and 28.5% living in rural zip codes as designated by the Federal Office of Rural Health Policy. Among non-users, the median distance was 24.5 miles, with 37% living 50 miles or further and 38% living in rural zip codes. The odds of using telemedicine for patients living in rural zip codes was 34.6% less than for patients living in non-rural zip codes (Odds Ratio: 0.654, 95% CI: 0.473-0.906).Conclusions: Telemedicine provides an important opportunity to reduce unnecessary patient exposure to healthcare settings and has the potential to decrease the financial toxicity and treatment burden associated with cancer care. Our findings suggest that telemedicine at our institution was accessible to patients of a wide range of ages, including a large percentage of older adults. While 37% of gynecologic oncology patients seen during this period lived in rural areas, we found that the odds of utilizing telemedicine were significantly lower among patients who lived in rural areas compared to those living in non-rural areas (p=0.0101). This highlights the importance of identifying barriers rural patients face in utilizing telemedicine services and developing strategies to improve their access.

Social health insurance consolidation and urban-rural inequality in utilization and financial risk protection in China

Universal health care is a long-term policy goal for health care reform in China. In 2016, China consolidated its urban and rural resident social health insurance programs into one program with a goal to reduce disparities between rural and urban populations. Using a nationally-representative sample of 14,967 individuals from the China Family Panel Studies surveys (2012–2018), we investigate whether the consolidation reduced gaps in total and out-of-pocket medical expenditure, and reimbursement between rural and urban residents. Our identification approach relies on an augmented difference-in-differences analysis whereby we compare the two programs that were consolidated to a different program that was not consolidated, before and after the consolidation. We find no evidence that the urban-rural gaps in these measures have narrowed as a result of the consolidation, at least in the near term. This surprising result may be partly explained by urban-rural inequality in access to care and provincial fiscal spending on health care. While these findings need to be confirmed with additional data and research, we call for continued efforts on addressing supply-side challenges, particularly in under-served areas.

Can a global budget improve health care efficiency? Experimental evidence from China.

Health care in China suffers from substantial allocative inefficiency in the delivery system and technical inefficiency within hospitals. To ameliorate this problem in rural areas, the Analysis of Provider Payment Reforms on Advancing China's Health (APPROACH) project shifted the payment method of China's rural health insurance scheme for county hospitals from fee-for-service to a novel global budget. In particular, APPROACH global budget incentivized system-level allocative efficiency by reimbursing county hospitals at higher tariffs for gatekeeping and averting out-of-county (OOC) admissions among local patients they could treat. APPROACH conducted a large-scale randomized controlled trial of the global budget in 56 counties (22 million enrollees) of Guizhou province during 2016-2017. Applying randomization inference to claims data, we find a significant shift of inpatient utilization and expenditure from OOC hospitals to county hospitals. At county hospitals, average expenditure per admission and length of stay decreased, though not significantly. Effects on readmissions show no clear sign of compromised quality. We further find limited effect heterogeneity with respect to treatment and hospital characteristics. Overall, APPROACH global budget may offer a framework for improving health care efficiency without sacrificing quality.

Disparities in COVID-19 Mortality Rates: Implications for Rural Health Policy and Preparedness.

Context:It is well established that rural communities face geographic and socioeconomic challenges linked to higher rates of health disparities across the United States, though the coronavirus disease 2019 (COVID-19) impact on rural communities is less certain.Objective:To understand the COVID-19 pandemic's impact on rural communities in Tennessee, investigate differences in rural-urban mortality rates after controlling for confounding variables, and inform state pandemic response policy.Design:A cross-sectional analysis of cumulative COVID-19 morality rates.Setting/Participants:Tennessee county-level COVID-19 mortality data from March 1, 2020, to January 31, 2021, were matched with county-level sociodemographic and health data from public datasets: Agency for Healthcare Research and Quality Social Determinants of Health, PLACES: Local Data for Better Health County Data, and the US Census Bureau. County status was defined using the 2013 National Center for Health Statistics Urban-Rural Classification.Main Outcome Measures:A negative binomial regression model estimated adjusted incidence rate ratio and 95% confidence intervals (CI) for rural compared with urban mortality. Unadjusted rate ratios and rate differences for COVID-19 mortality in rural versus urban counties were compared with those for influenza and pneumonia and all-cause mortality over the past 5 years.Results:During the study period, 9650 COVID-19 deaths occurred across 42 urban and 53 rural counties. Controlling for county-level sociodemographic characteristics, health care access, and comorbidities, incidence rate ratio was 1.13 (95% CI, 1.00-1.28, P < .05) for rural as compared with urban deaths. Unadjusted COVID-19 mortality risk difference between rural and urban counties was greater (61.85, 95% CI, 54.31-69.31) than 5-year influenza and pneumonia rural-urban risk difference (12.57, 95% CI, 11.16-13.00) during 2015-2019.Conclusions:COVID-19 mortality rates were greater for populations living in Tennessee's rural as compared with urban counties during the study period. This differential impact must be considered in public health decision making to mitigate COVID-19.

Impact of Environmental and Socioeconomic Factors on Semen Quality in the United States

ABSTRACT Introduction It has been stated that sperm counts worldwide have declined by as much as 50% since 1973, with increasing environmental pollutants cited as one of many possible root causes. Recent theories challenge the validity of these contentious claims, such as the sperm count bioavailability (SCB) hypothesis, which asserts that global sperm health remains highly heterogenous across bodies, ecologies, and even time periods. Specifically, the impact of ecological factors on sperm health in the United States remains grossly understudied. Objective To examine the effect of environmental and socioeconomic factors, such as air quality, rurality, median income, and poverty rates, on sperm quality in the United States. Methods An ecological study was conducted using a nation-wide sample obtained from Dadi Kit, a company which produces at-home sperm testing kits, containing the zip code, age, and semen analyses for all subjects consenting to research. Subjects were linked via zip code to national, geographical databases on Air Quality Index (Environmental Protection Agency), rurality (Federal Office of Rural Health Policy), median household income (Census Bureau), and poverty rates (Census Bureau). Comparative analyses were conducted on Stata (College Station, TX). Linear regression models adjusted for age were used to analyze associations of sperm concentration (millions/mL of semen), motility (%), and semen volume (mL) with each exposure variable. Results A total of 1,343 male subjects with a median age of 32 (interquartile range [IQR]: 28-38) were included, representing 1,035 unique zip codes and 306 United States counties. Median values of sperm concentration, motility, and semen volume were 126.8 million/mL (IQR: 64.2-226.5 million/mL), 25.9% (IQR: 15.7-38%), and 2.2 mL (IQR: 1.4-3.6 mL), respectively. As illustrated in Table 1, air quality index, median household income, and poverty rates were not significantly correlated with any of the three semen parameters measured. A significant negative correlation between rurality and sperm motility was observed (P=.04), yet no association was observed with sperm concentration or semen volume. Conclusions Our study found no apparent link between air quality, median income, or poverty rates and any of the semen parameters measured in our nation-wide sample, while rurality was negatively associated with sperm motility only. Further longitudinal studies at the individual level are needed to dismiss a link between socioeconomic factors and sperm quality in the United States. Disclosure Yes, this is sponsored by industry/sponsor: Dadi Kit Clarification No industry support in study design or execution Any of the authors act as a consultant, employee or shareholder of an industry for: Dadi Kit

The Complex Intersection of Race and Rurality: The Detrimental Effects of Race-Neutral Rural Health Policies.

In this commentary, we discuss our experiences as women of different races growing up in the same rural area and how these experiences relate to health and health policy. Despite nearly five million Black people living in nonmetro areas, rural Black Americans face erasure in the rural narrative and the policies enacted to support them. This is detrimental to the overall uplifting of rural communities and to the elimination of the compounded disparities of being rural and Black. We aim to bring to life rural America for Black and White residents and the impact of the policies that shape it.