Rural North Research Articles

Implementation characteristics that may promote sustainability of a rural physical activity initiative: examination of Play Streets through the lens of community implementers

BackgroundPlay Streets, which are community-based environmental initiatives where public spaces/streets are temporarily closed to create safe, low-cost physical activity opportunities, have demonstrated feasibility and physical activity benefit in rural US areas. Yet, information is needed to identify implementation characteristics that may promote sustainability. This study examined rural Play Streets implementation characteristics that could impact sustainability from local partners’ perspectives.MethodsSixteen Play Streets implementation team members in rural Maryland, North Carolina, Oklahoma, and Texas, USA, participated in interviews. Semi-structured in-person individual and group interviews were conducted in the fall of 2018 (after Play Streets implementation in 2017 and 2018), recorded, and transcribed verbatim. Transcripts were analyzed using iterative, content analyses. Coding frameworks were based on the Public Health Program Capacity for Sustainability Framework, and emergent themes were also identified.ResultsInterviewees’ perceived characteristics for facilitating Play Streets implementation aligned with the Public Health Program Capacity for Sustainability Framework: funding stability, political support, partnerships, organizational capacity, program adaption, and communication. Interviewees also noted the importance of cultural alignment/support and the reciprocal impact of community connectedness/engagement.ConclusionsFuture research should examine the reciprocal role of public health impacts, as both outcomes and factors which may influence sustainability.

‘You get sick when you go to the hospital!’ Sickening landscapes, digital exclusiveness, and iatrogenesis in rural North China

AbstractA local narrative current in North China's Shandong Province paints the hospital as a place where people become ill. This article foregrounds older rural people's embodied experience of navigating the medical system. This involves humiliation and feelings of incompetence in their interactions not only with other people whom they see as more sophisticated than them but also with unfamiliar things such as elevators and digital payment platforms. ‘Sickening landscapes’, a concept built upon this narrative, expands the notion of therapeutic landscapes to bring into sharp relief the negative effects of places and things and the embedded health inequities. It offers a native account of iatrogenesis, as something arising from mundane interactions with physical spaces, technologies, and people, which expands the current focus of clinical iatrogenesis on medical error, malpractices, and nosocomial infections. Incorporating the notion of ‘sickening landscapes’ into the theory of care helps us better attend to the trivial, easily neglected things and places that directly bear on the health and well‐being of marginalized social groups.

Abstract PO1-09-05: Reversing Rural Disparity Through Increased Access to Breast Care Using Model of Academic-Community Collaboration

Abstract Background: Rural disparity in Breast Cancer (BC) often relates to poor geographic access. We are small county in rural North Carolina with historically poor outcomes, including more advanced stages of BC at presentation, higher mastectomy rates, and higher BC-specific mortality rates than elsewhere. Beginning in 2002 we increased access to care by construction of a 19-bed Critical Access Hospital. With a higher median age population (10 years older), and cancer as the number one cause of death (30% of all deaths), we began to increase access to services with focus on cancer. Two decades later, we still do not provide all aspects of care locally, but through a model of collaboration we have increased access to all aspects of cancer care. Breast Cancer is the most common, and this report details the reversal in disparity seen rurally based on our model of collaboration with both a regional community cancer program and academic cancer program. Methods: We partnered with academic and community cancer centers in nearby counties to increase access to imaging, cancer specialists, radiation therapy and chemotherapy services, and support services for breast care. When we could not provide these services locally, we helped navigate patients to these other facilities to improve access. We invited dedicated breast surgeon from community cancer program to attend clinic weekly in our area. We created virtual breast-specific tumor boards to discuss 100% of cases prospectively, with improved access to pathologists, geneticists, fellowship-trained imaging specialists, breast surgeons and other multi-disciplinary care members (reconstructive surgery, PT/OT, integrative medicine, GYN). We became cancer accredited with both COC and NAPBC. We compare metrics pre/post-improvements. Results: Baseline: 1. Mortality rates: (2002-2006) 5-year BC mortality rates in our region averaged 32.3/100,000 population which was in the top quartile for the state, 30% higher than the state average. 2. Stages at presentation: 47% of BC stages were early (stages 0/1) in our service region compared to 62% elsewhere (NCDB data). Stage IV represented 6% in our region versus 4% elsewhere. 2500 mammograms/year at hospital at baseline. 3. Surgery/Radiation Therapy: Mastectomy rates averaged >50% in region, with correspondingly lower breast conserving rates than elsewhere due to lack of access to breast surgeons and radiation therapy services locally. Closest RT facility 80 miles. 4. Distances to high quality breast care averaged 150 miles. Closest Academic/Community Cancer Program 2-hour drive (one way). Post Collaboration: 1. Mortality rates: (2015-2019), 5-year BC mortality rates in our region averaged 16.3/100,000 population which is in the lowest quartile, 20% lower than the state average. 2. Stages at presentation: 74% of BC stages are early (stages 0/I) in our region versus 68% elsewhere. Stage IV now below parity with 3% locally versus 4% nationally. More than 5100 mammograms/year done currently at local hospital. 3. Surgery/Radiation Therapy: Mastectomy rates average 21%, with partial mastectomy rates of 79% in our area versus 70% elsewhere (NAPBC data) with RT services available locally. 4. Distances to quality breast care average 20 miles, and we are nationally accredited program in breast care as a critical access hospital. Analytic case load is now triple baseline numbers. Conclusion: We reversed the trend in rural disparity in breast cancer outcomes through model of collaboration. We increased screening rates locally, doubling the number of screening/diagnostic exams, increased the percentage of early stage at diagnosis, halved our mastectomy rates, and reduced BC-specific mortality 50% relative to baseline (and now 20% lower than state). We are now at parity with most BC-specific quality metrics reflecting a huge shift in rural disparity, which could only be achieved rurally through collaboration. Reversing Rural Disparity Through Increased Access to Breast Care Using Model of Academic-Community Collaboration This table depicts the changes in our region over time, which have brought us to parity with Breast Care nationally. Citation Format: Charles Shelton, Antonio Ruiz. Reversing Rural Disparity Through Increased Access to Breast Care Using Model of Academic-Community Collaboration [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-09-05.

The Impact of Agroecosystems on Nitrous Acid (HONO) Emissions during Spring and Autumn in the North China Plain

Solar radiation triggers atmospheric nitrous acid (HONO) photolysis, producing OH radicals, thereby accelerating photochemical reactions, leading to severe secondary pollution formation. Missing daytime sources were detected in the extensive HONO budget studies carried out in the past. In the rural North China Plain, some studies attributed those to soil emissions and more recent studies to dew evaporation. To investigate the contributions of these two processes to HONO temporal variations and unknown production rates in rural areas, HONO and related field observations obtained at the Gucheng Agricultural and Ecological Meteorological Station during spring and autumn were thoroughly analyzed. Morning peaks in HONO frequently occurred simultaneously with those of ammonia (NH3) and water vapor both during spring and autumn, which were mostly caused by dew and guttation water evaporation. In spring, the unknown HONO production rate revealed pronounced afternoon peaks exceeding those in the morning. In autumn, however, the afternoon peak was barely detectable compared to the morning peak. The unknown afternoon HONO production rates were attributed to soil emissions due to their good relationship to soil temperatures, while NH3 soil emissions were not as distinctive as dew emissions. Overall, the relative daytime contribution of dew emissions was higher during autumn, while soil emissions dominated during spring. Nevertheless, dew emission remained the most dominant contributor to morning time HONO emissions in both seasons, thus being responsible for the initiation of daytime OH radical formation and activation of photochemical reactions, while soil emissions further maintained HONO and associated OH radial formation rates at a high level, especially during spring. Future studies need to thoroughly investigate the influencing factors of dew and soil emissions and establish their relationship to HONO emission rates, form reasonable parameterizations for regional and global models, and improve current underestimations in modeled atmospheric oxidation capacity.

Subsidy-Dominated Non-Farm Income Improves Herder Household Livelihoods and Promotes Income Equality in North Tibet, China

The non-farm sector is critical in supporting sustainable economies, alleviating poverty, and improving human well-being. However, the drivers of non-farm income and how it impacts income inequality remain underexplored, especially in alpine regions worldwide. Herein, we conducted face-to-face interviews using semi-structured questionnaires with 665 herder households across 54 villages in North Tibet from 2018 to 2020. We assessed the role of non-farm income in household economies and explored the determinants of household income using basic statistical methods, Gini coefficient analysis, and mixed-effects modeling. Our results showed that non-farm income accounted for approximately 80% of the total household income. It contributed to lower income inequality in rural North Tibet, with government subsidies playing a more vital role than wages and business income in this reduction. Results indicated that the number of migrant workers was the most significant positive predictor of both non-farm income and total household income, whereas livestock units dominated farm income. Given the modest contributions of livestock-derived income (~5%) and wage and business revenues (~18%) to overall earnings, this study suggests that policies should primarily focus on strengthening rural livestock husbandry. Simultaneously, it is imperative to foster environments that encourage entrepreneurship and non-farm activities and to expand access to skill-based training. Such initiatives and measures are essential for diversifying livelihood strategies and improving resident welfare in North Tibet.

Experiences from Running a Participatory Media Platform for Women and Led by Women in Rural North India

Patriarchal practices and other socio-cultural norms in rural North India often prevent women from participating in digital platforms. In this paper we present a voice-based participatory community media platform that runs over simple voice-based phone calls. The platform is meant for women users and is led by women and has been used by 12,222 women users over the course of 20 months. We conduct a qualitative study and present several innovations, such as creating a safe space for women, which have contributed to more participation of women on the platform. We present a framework which can serve as a guidance for researchers and practitioners who want to set up digital platforms for women users.

Community health worker outreach to farmworkers in rural North Carolina: Learning from adaptations to the SARS-CoV-2 pandemic.

Community health workers represent a critical part of the health outreach and services for migrant and seasonal farmworkers ('farmworkers') in rural areas of the United States. We sought to identify adaptations to farmworker patient engagement and health outreach made by community health workers during the first 18 months of the COVID-19 pandemic. In this qualitative study, we used semi-structured interviews with community health workers from August 2020 to February 2022 (n = 21). Two coders used thematic analysis to identify three themes related to the experiences of community health workers in conducting health education and outreach to farmworkers prior to and following the onset of the pandemic. We found themes related to pre-pandemic outreach efforts to provide health education resource sharing with farmworkers and pandemic-related outreach efforts that included adoption of porch drops and distanced delivery of health education, adaptation of modes of health education and communication through technology and the internet, and taking on new roles related to COVID-19. Finally, we identified changes that reverted after the pandemic or will continue as adaptations. Community health workers created practice-based innovations in outreach in response to the COVID-19 pandemic. These innovations included new COVID-19 related roles and new modes of health education and outreach, including the use of digital resources. The changes developed for emergency use in COVID-19, particularly related to internet and technology, have likely altered how community health workers conduct outreach in North Carolina going forward. Funders, community health worker training programs, and researchers should take note of these innovations. Community health workers who typically come from patient populations and provide critical navigation and connection with the health care system advised on the design and creation of this research project, including serving on an advisory board. Two authors have experience working as community health workers.

“Just Did The Best That I Could Do”: CPS Social Workers’ Perceptions of Self-Efficacy in Legal Aspects

AbstractChild protective services (CPS) social workers assess safety and risk needs during abuse and neglect investigations to determine if legal interventions are needed. However, only 60% of abuse and neglect cases have safety and risk assessed during the investigatory process in North Carolina. This study aimed to explore the perceptions of self-efficacy among rural North Carolina CPS social workers in child abuse and neglect investigations. Understanding CPS social workers’ perceptions of self-efficacy and factors that may influence their self-efficacy is vital to improving job satisfaction, retention, and the legal and investigative processes relating to child abuse and neglect. A purposive sampling approach was used to recruit nine CPS social workers in rural counties in North Carolina. Through a process of open, axial, and selective coding, we conclude that a CPS social worker’s self-efficacy is impacted by factors relating to leadership and legal teams, longevity, previous social work experience, and paperwork and caseload demands.

Power & Moral Capital - A “Theory of Access” for People Receiving Public Assistance in Rural USA

ABSTRACT In-depth interviews with people using public assistance in a rural place in the United States demonstrated barriers to accessing resources through formal work and self-provisioning and the ability to benefit from use of public assistance—low income means-tested medical, nutritional, financial, or other services from state, federal, or non-governmental agencies. The Theory of Access (TOA) was used as a framework to organize participant narratives and an intersectional perspective to a multidimensional theory of power was used to demonstrate how moral capital is levied and reproduced. Findings from the TOA revealed intersectionalities in barriers to accessing resources across structural, relational, physical, and psychosocial access mechanisms for women, particularly women of color with dependent children, pregnant women of color, and women with disabilities. While TOA demonstrated need for public assistance, the double power of moral capital demonstrated how the benefits of public assistance to human dignity and welfare were reduced by (1) disciplinary tactics to reject public assistance and (2) reproduction of broader moral imperatives. The connections between TOA and moral capital contribute an intersectionality approach for understanding the multiple disadvantages of people with the lowest incomes, which helps to explain low rates of self-provisioning and public assistance use despite high need across the rural Global North.

Addressing Physical Inactivity in Aging, Rural Communities

ABSTRACT Background Many individuals do not engage in adequate levels of physical activity, despite its role in the prevention and treatment of various diseases. Physical activity would be especially beneficial for older adults in addressing age-related concerns such as disease, cognitive dysfunction, and fall risk, all of which are mitigated via increased activity. Rural counties exhibit an aging population with high rates of sedentary behavior, requiring innovative approaches to address physical inactivity in an appropriate and accessible manner. Methods The Aging Well Program, under Blue Cross North Carolina’s Institute for Health and Human Services, provides assessments for concerns seen in the rural western North Carolina aging populations, such as fall risk, physical inactivity, food insecurity, and cognitive health. Exercise consultations with a clinical exercise physiologist were developed to help address the concerns emerging from the findings of the assessments. Results The Aging Well program has served 134 older (mean age: 74 years) rural adults. The exercise consultations are ongoing and have demonstrated several beneficial outcomes, including referrals to appropriate health professionals, the initiation or advancement of exercise programs, and the education of concepts important in exercise prescription. Although consultations have shown positive results, there is a need to address the sustainability of the program. Conclusion There is an urgent need to address physical inactivity in older, rural populations. Multiple barriers exist and vary based on location, resources, and individuals dwelling within those counties. Creating programs that are accessible, feasible, and sustainable should be a high priority in these areas.

What to make of a Sultan's tear: Phaticity, praise poetry, and social infrastructures in the Sultanate of Oman

AbstractThe distributive political economy of contemporary Arab Oman yields a status‐differentiated social infrastructure composed of elites who distribute and non‐elites who, in many ways, rely on those distributions. The construction of communicative links within social infrastructures via the performance of sung poetry depends on the phaticity of the link being activated. For Omani poets, different linguistic performance genres telescope the vast social distance between elites who listen and non‐elites who sing in different ways and with different results. Omani poets from the rural north of the country conduct cross‐class social contact—conceptually “vertical” social infrastructural movement—by way of two contrasting genres of Arabic praise poetry: a one‐off request or statement, the solo qasida, and a recognitive, addressive choral form that reciprocally establishes and evaluates such vertical relationships, the 'āzī. I argue that the metapragmatic distinctions that Omani poets draw between these two genres reveal a subtle phatic ideology that allows certain modes of communicative contact to index deeper, cross‐class social ties within grand public performances, while simultaneously reinforcing tacit norms of elite avoidance of non‐elites in everyday social intercourse.

Seasonal variations in social contact patterns in a rural population in north India: Implications for pandemic control.

Social contact mixing patterns are critical to model the transmission of communicable diseases, and have been employed to model disease outbreaks including COVID-19. Nonetheless, there is a paucity of studies on contact mixing in low and middle-income countries such as India. Furthermore, mathematical models of disease outbreaks do not account for the temporal nature of social contacts. We conducted a longitudinal study of social contacts in rural north India across three seasons and analysed the temporal differences in contact patterns. A contact diary survey was performed across three seasons from October 2015-16, in which participants were queried on the number, duration, and characteristics of contacts that occurred on the previous day. A total of 8,421 responses from 3,052 respondents (49% females) recorded characteristics of 180,073 contacts. Respondents reported a significantly higher number and duration of contacts in the winter, followed by the summer and the monsoon season (Nemenyi post-hoc, p<0.001). Participants aged 0-9 years and 10-19 years of age reported the highest median number of contacts (16 (IQR 12-21), 17 (IQR 13-24) respectively) and were found to have the highest node centrality in the social network of the region (pageranks = 0.20, 0.17). A large proportion (>80%) of contacts that were reported in schools or on public transport involved physical contact. To the best of our knowledge, our study is the first from India to show that contact mixing patterns vary by the time of the year and provides useful implications for pandemic control. We compared the differences in the number, duration and location of contacts by age-group and gender, and studied the impact of the season, age-group, employment and day of the week on the number and duration of contacts using multivariate negative binomial regression. We created a social network to further understand the age and gender-specific contact patterns, and used the contact matrices in each season to parameterise a nine-compartment agent-based model for simulating a COVID-19 epidemic in each season. Our results can be used to parameterize more accurate mathematical models for prediction of epidemiological trends of infections in rural India.

An Exploration of Rural Housing Insecurity as a Public Health Problem in California's Rural Northern Counties.

Although widely acknowledged as an important social determinant of health, until recently researchers and policymakers have primarily approached housing insecurity as an urban issue, obscuring the visibility of its impacts in rural contexts, including the ways in which housing insecurity intersects with other health and structural inequities facing rural populations. Working to address this gap in the existing literature, this paper explores the experiences of housing insecurity in a rural context by reporting on an analysis of 210 in-depth interviews with 153 adults between the ages of 18-35, living in California's rural North State, a relatively overlooked far northern region of the state comprised of 12 north central and north eastern counties. Using in-depth qualitative interview data, we conducted an exploratory pattern-level analysis of participants' narratives structured by four dimensions of housing insecurity defined in the literature (housing affordability, housing stability, housing conditions, and neighborhood context). Drawing attention to the pervasiveness of rural housing insecurity within our sample, this analysis highlights the unique ways in which rurality creates distinct experiences not currently captured in the existing literature. Further research is needed across different types of rural communities to better understand the various ways that housing insecurity affects the everyday lives and health of rural residents. By grounding research within the experiences of rural residents, we are better able to respond to the crisis of rural housing insecurity and develop solutions that are tailored to rural residents' unique needs.

An Exploratory Study of the Perceived Need for and Acceptability of a Healthy Frozen Meal Product Among Rural Corner Store Customers in North Carolina

ABSTRACT This pilot study assesses barriers to obtaining healthy affordable food and the early-stage acceptability of a novel subsidized healthy frozen meal product designed to address food insecurity and nutritional status among corner store customers in rural North Carolina. A convenience sample of 50 customers were surveyed to examine the perceived availability of healthy food options, barriers to maintaining healthy diets, food shopping and consumption habits, and reception of the product. Findings confirmed barriers to obtaining healthy foods that the product seeks to address, the validity of corner stores as the intervention site, and approval of the product’s taste and concept.

The Social and Home Environment: Impacts of Determinants of Health on Atopic Dermatitis, Pathways Toward Solutions, and Unique Considerations for Rural and Remote North American Indigenous Populations

The Social and Home Environment: Impacts of Determinants of Health on Atopic Dermatitis, Pathways Toward Solutions, and Unique Considerations for Rural and Remote North American Indigenous Populations

Assessing a Community-Based Maternal Self-Efficacy Intervention in Rural India using a Quasi-Experimental Design

More than 175 million people in India live below the poverty line and are concentrated in rural areas. Families in rural Indian communities may benefit from interventions that support long-term well-being. Maternal self-efficacy (MSE) may be an important target for interventions given prior associations with positive maternal and child outcomes. The present study examined MSE in a pilot community-based group intervention delivered in rural North India. Using convenience sampling recruitment and a quasi-experimental design, 97 mothers (79 self-identified as low-caste) with at least one child between 0–24 months who engaged in the intervention were compared with a matched control group ( n = 219; 114 low-caste). Findings suggest that participation in the intervention was associated with higher MSE (ß = .294, p = .020) and the positive association was stronger amongst mothers from low-caste groups who participated in the intervention (ß = .390, p = .008). MSE may be malleable with the right approach and could be an important target for public health interventions, particularly for low-caste groups in rural India.

Prevalence and sociodemographic determinants of common mental disorders (CMDs) symptoms in a rural adult population of Haryana, North India.

Common mental disorders (CMDs), including depression, anxiety, and somatoform disorders, affect all stages of life and impact individuals, families, and communities. This study aimed to determine the magnitude of CMDs and their sociodemographic determinants in the adult population of a rural block in North India. A cross-sectional, quantitative, community-based study was conducted among adult residents of a rural block in Haryana, North India, using a multistage random sampling technique. The Hindi version of the General Health Questionnaire (GHQ-12), a well-validated tool, was used to screen participants for CMDs. Scores of 4 or above denoted the presence of CMDs. Bivariate analyses were performed to determine the associations between CMDs and sociodemographic characteristics. Of the 180 residents selected for the study, most were women (60.0%) and aged between 31 and 50 years (52.3%). The prevalence of CMDs symptoms in the study population was 20.0%. The presence of CMDs symptoms was significantly higher among those who were aged 60 years or older [OR=12.33, 95% CI 3.21-47.38], widowed, divorced or separated [OR=7.50, 95% CI 1.09-51.52], illiterate [OR= 6.25, 95% CI 2.84-13.77], had monthly family income below 10,000 INR [OR=3.33, 95% CI 1.54-7.20], had any chronic physical illness [OR=8.28, 95% CI 3.70-18.56] and had a family history of any psychiatric illness [OR=5.56, 95% CI 1.52-19.42]. The burden of CMDs was quite high among adults in rural North India. The presence of CMDs was closely associated with sociodemographic characteristics. Primary care and community-based settings need to screen for, diagnose, and manage CMDs to address this growing problem.

Provider perspectives on delivering telemental health services in rural North Carolina: Field report.

Provider perspectives on delivering telemental health services in rural North Carolina: Field report.

Maternal understanding and practices of breastfeeding and infant feeding in rural North Karnataka: a cross sectional study

Background: Child-malnutrition is a critical global concern supported by substantial evidence. Recognizing optimal infant and young child-feeding practices as pivotal in combating malnutrition is crucial. Methods: This was a cross-sectional study conducted through house-to-house survey in Ukkali and Shivanagi villages for period of 6 months from February 2018 to July 2018. A pretested-questionnaire was administered to 133mothers of 6 to 12-month-old children, collecting socio-demographic data, knowledge, attitudes, and practices regarding prelacteal, breastfeeding, and complementary-feeding. Results: Knowledge gaps emerged, with only 50% understanding colostrum's importance. Limited awareness of exclusive breastfeeding (65%) and extended breastfeeding (31.57%) was observed. Prelacteal-feeding was widespread (52.63%), with sugar-water being a prevalent choice (21.8%). Most mothers (over 90%) opted for breastfeeding, yet timely initiation (27.6%) and exclusive-breastfeeding (30%) were suboptimal. Complementary-feeding initiation (15%) and minimum-meal-frequency adherence (13.3%) were low. Meal-diversity was deficient in over 60%. Conclusions: Bridging knowledge gaps and promoting optimal-feeding-practices through targeted nutritional education is essential. This study underscores the importance of addressing misconceptions, enhancing early-breastfeeding, and ensuring proper complementary-feeding to improve child-health outcomes. Socio-demographic-factors must be considered when designing educational material and interventions in rural-settings.

WORKING TOGETHER TO PROVIDE GERIATRIC CARE: INTERDISCIPLINARY TEAM CREATION AND EVALUATION IN CANADA

Abstract Prince Edward Island is Canada’s smallest province (pop. 160,000) and has one of the oldest populations in Canada. While there is a robust and growing geriatrics program through provincial healthcare, it consists exclusively of medical providers (i.e., geriatricians and nurse practitioners). An opportunity for formal interprofessional collaboration presented itself when the University of Prince Edward Island began a Doctor of Psychology (PsyD) program in 2019. Soon thereafter, we established an interdisciplinary team between the PsyD and the provincial geriatrics programs. The goals of the team included: 1) enhancing care for older adults on the island, 2) providing training for PsyD students, and 3) increasing interprofessional collaboration and learning. In an evaluation of the first year of the collaboration, we collected data on the types of referrals and characteristics of the patients referred (e.g., number of medications), and asked all providers on the team (N=4 geriatricians, N=9 nurse practitioners, and N=4 psychology student clinicians) to answer open ended questions on the highlights and challenges of establishing the team, the organization of formal team meetings, and provision of patient care. Of the 74 patients seen by psychology, reasons included cognitive or psychodiagnostic assessment (N=22, 30%), psychotherapy (N=20, 27%), caregiver support (N= 25, 34%), or multiple services (i.e., both assessment and intervention; n=7, 10%). Additional patient characteristics will be shared, as well as themes from provider survey responses. Our program has implications for other areas in rural North America, particularly training opportunities built into our team functioning.