Rural United States Research Articles

Baccalaureate nursing students' engagement with end-of-life curriculum: A grounded theory study

BackgroundThe art of being prepared to support patients and their families during end of life experiences is not always emphasized in nurse education. Despite the efforts from the American Association of Colleges of Nursing and End of Life Nursing Education Consortium (ELNEC), only 25% of nursing schools across the United States are using their modules. ObjectiveThe purpose of this study was to explore how student nurses engage with end of life education. DesignQualitative study using a grounded theory approach. SettingBaccalaureate nursing program located in the rural agricultural western United States. ParticipantsUsing purposive sampling, a single cohort of baccalaureate student nurses in two focus groups (n = 17; n = 23). MethodsUsing a grounded theory approach, student experiences and engagement with the curriculum were explored. Using the constant comparative method, three researchers coded the data independently and then came together to reach consensus on themes and for the development of the conceptual model. ResultsThree categories emerged from the data to describe the student engagement with the curriculum: Novice, Evolving, and Prepared. The central theme for the Novice students was Being Afraid. Students expressed fear over the unknown and not knowing what to say or do. Becoming Aware was the central theme for the Evolving students which included a blend of being aware of their deficiencies as well as the important aspects of end of life care. The final category was Prepared. The theme for this category was Becoming Accomplished, which included recognition of respectful care, disrespectful care, team work, and advocacy. ConclusionEnd of life education is essential for nursing students to provide appropriate care at end of life, as well as providing improved knowledge, attitudes, and confidence of students. The End of Life Nursing Education Consortium modules, placed strategically within the curriculum, allow nursing students to move through the process of Being Afraid, to Becoming Aware, and finally Becoming Accomplished upon graduation.

Televascular consultation is one answer to rural vascular surgery shortage

Telemedicine provides an opportunity for virtual consultation between physicians and patients in remote locations. We sought to evaluate whether telemedicine consultation for vascular surgery can replace direct visits for patients in remote areas. Patients undergoing telemedicine consultation from 2014–2019 at the Veterans Affairs Medical Center (VAMC) with a large rural catchment area, were reviewed. Primary outcomes included diagnosis, type and number of telemedicine visits, and types of surgical procedures scheduled after initial visit. 574 patients participated in 708 out-patient telemedicine consultations conducted by four vascular surgeons and two advanced practitioners. Visits took place at 21 clinics across Minnesota (n = 305), North Dakota (n = 96), South Dakota (n = 82), Wisconsin (n = 20), and Iowa (n = 2) with an average distance of 159 miles from the VAMC. There were 429 (75%) new patient visits and 279 (25%) follow-ups. After initial telemedicine consultation, 236 (55%) patients were booked for procedures. Telemedicine is feasible for vascular surgery consultation and increases patient convenience with decreased overall travel expense and wait time. Telemedicine can be a viable solution to the shortage of vascular surgeons in the rural United States.

The Fine Line: Rural Justice, Public Health and Safety, and the Coronavirus Pandemic

In this article, we provide an early glimpse into how the issues of public health and safety played out in the rural United States during the coronavirus pandemic, focusing on Washington State. We utilize a combination of news articles and press releases, sheriff’s department Facebook posts, publicly available jail data, courtroom observations, in-depth interviews with those who have been held in rural jails, and interviews with rural law enforcement staff to explore this theme. As elected officials, rural sheriffs are beholden to populations that include many who are suspicious of science, liberal agendas, and anything that might threaten what they see as individual freedom. At the same time, they expect local law enforcement to employ punitive measures to control perceived criminal activity in their communities. These communities are often tightly knit, cohesive, and isolated, with high levels of social support both for community members and local leaders, including sheriffs and law enforcement. This complex social context often puts rural sheriffs and law enforcement officers in difficult positions. Given the multiple cross-pressures that rural justice systems faced in the wake of the COVID-19 pandemic, we explore the circumstances in which they attempted to protect and advocate for the health and safety of both their incarcerated and their nonincarcerated populations. We find that certain characteristics of rural communities both help and hinder local law enforcement in efforts to combat the virus, but these characteristics typically favor informal norms of social control to govern community health. Thus, rural sheriff’s departments repeatedly chose strategies that limited their abilities to protect populations from the disease, in favor of appearing tough on crime and supportive of personal liberty.

Evaluating disparities in access to obstetric services for American Indian women across Montana.

Pregnant women across the rural United States have increasingly limited access to obstetric care, especially specialty care for high-risk women and infants. Limited research focuses on access for rural American Indian/Alaskan Native (AIAN) women, a population warranting attention given persistent inequalities in birth outcomes. Using Montana birth certificate data (2014-2018), we examined variation in travel time to give birth and access to different levels of obstetric care (i.e., the proportion of individuals living within 1- and 2-h drives to facilities), by rurality (Rural-Urban Continuum Code) and race (White and AIAN people). Results point to limited obstetric care access in remote rural areas in Montana, especially higher-level specialty care, compared to urban or urban-adjacent rural areas. AIAN women traveled significantly farther than White women to access care (24.2 min farther on average), even compared to White women from similarly rural areas (5-13 min farther, after controlling for sociodemographic characteristics, risk factors, and health care utilization). AIAN women were 20 times more likely to give birth at a hospital without obstetric services and had less access to complex obstetric care. Poor access was particularly pronounced among reservation-dwelling AIAN women. It is imperative to consider racial disparities and health inequities underlying poor access to obstetric services across rural America. Current federal policies aim to reduce maternity care professional shortages. Our findings suggest that racial disparities in access to complex obstetric care will persist in Montana unless facility-level infrastructure is also expanded to reach areas serving AIAN women.

Evidence-Based Supported Employment in the Rural United States: Challenges and Adaptations.

The authors examined how individual placement and support (IPS), an evidence-based model of supported employment, has been successfully adapted in rural communities across the United States. Interviews with 27 key informants in 15 states with successful IPS programs in rural communities identified challenges that IPS workers faced because of rurality and the work-around methods they used to overcome these challenges. The authors conducted a thematic analysis of interviews. Significant challenges to implementing IPS in rural areas included limited availability of public transportation, Internet connectivity, employment opportunities, and workforce. The work-around strategies used by IPS teams differed in relation to local circumstances and cultures, but effective services generally used natural supports for transportation, provided computer access for job applicants, developed relationships with local employers, and hired IPS workers with local knowledge. The adaptations made to IPS in rural areas are specific to local communities but retain core IPS principles.

Indoor fine particulate matter and demographic, household, and wood stove characteristics among rural US homes heated with wood fuel.

Household heating using wood stoves is common practice in many rural areas of the United States (US) and can lead to elevated concentrations of indoor fine particulate matter (PM2.5 ). We collected 6-day measures of indoor PM2.5 during the winter and evaluated household and stove-use characteristics in homes at three rural and diverse study sites. The median indoor PM2.5 concentration across all homes was 19µg/m3 , with higher concentrations in Alaska (median=30, minimum=4, maximum=200, n=10) and Navajo Nation homes (median=29, minimum=3, maximum=105, n=23) compared with Montana homes (median=16, minimum=2, maximum=139, n=59). Households that had not cleaned the chimney within the past year had 65% higher geometric mean PM2.5 compared to those with chimney cleaned within 6months (95% confidence interval [CI]: -1, 170). Based on a novel wood stove grading method, homes with low-quality and medium-quality stoves had substantially higher PM2.5 compared to homes with higher-quality stoves (186% higher [95% CI: 32, 519] and 161% higher; [95% CI:27, 434], respectively). Our findings highlight the need for, and complex nature of, regionally appropriate interventions to reduce indoor air pollution in rural wood-burning regions. Higher-quality stoves and behavioral practices such as regular chimney cleaning may help improve indoor air quality in such homes.

The devil’s armpit and other tales from the rural rustbelt: Interrogating the practice and process of Un/masking in a postcritical ethnography about place

Resistance to simple narratives in education research comes from the stance that they render findings useless for the political work of understanding contexts of education as they exist today. This paper interrogates three stories of masking choices from a four year postcritical ethnographic study in the rural rustbelt Midwestern United States. These stories make visible how masking operates as both process and product within and part of white supremacist and colonizing systems. The author calls critical qualitative and postcritical researchers to interrogate the role of protection, answerability, and specificity in their work towards justice in terms of masking.

Unsettled Belonging in Complex Geopolitics: Refugees, NGOs, and Rural Communities in Northern Colorado

In Colorado, meat processing and packing industries profit from the low-wage labor of foreign born workers and refugees in particular. Scholars and journalists have examined the hazardous and environmentally unjust workplace conditions in meatpacking, and detailed refugee struggles in North American resettlement geographies. Our research builds from this work to examine how multi-scalar geopolitical processes shape processes of refugee resettlement and refugee labor in Colorado’s meatpacking industries. Methods for this work include analysis of secondary data and twenty-two semi-structured interviews with various actors knowledgeable about refugee resettlement and/or agricultural production in Colorado. We argue various intersecting geopolitical processes—from immigration raids of meatpacking plants to presidential-level xenophobic discourses and ensuing immigration policies—interact to impact refugee resettlement and participation in the meat production sector. Moreover, while the U.S.’s neoliberal model of outsourcing resettlement to non-governmental organizations (NGOs) has been widely critiqued, we argue NGO employees, many of whom identify as foreign-born and/or refugees, work to build connection and belonging among refugees in challenging resettlement environments. We suggest a feminist geopolitics approach, which examines how the “global” and the “intimate” are deeply intertwined, is a useful perspective for understanding complicated racialized spaces in the rural United States, including efforts to build connections and empower refugee identities.

Stigma in place: Black gay men's experiences of the rural South.

Black gay men (MSM) in the rural United States South are inequitably burdened by stigmatization and the HIV epidemic. Drawing from twelve oral history interviews with middle-aged and older Black gay narrators from rural North Carolina, this research explores the impact of sexual marginalization and the HIV epidemic on lived experiences of the rural South. Despite describing increasingly empowered views of HIV and sexual health, narrators expressed persistent difficulty managing social determinants of HIV vulnerability-sexual stigma and disconnection from LGBTQ collectivity. Narrators reported better managing sexual marginalization over their lifetimes in urban settings and places outside of the South such as New York (NY). This research suggests stressful structural and interpersonal experiences of stigma may define lived experiences of particular settings.

Negotiating the Northwoods: Anti-establishment rural politics in the Northeastern United States

While recent scholarship on rural politics in the United States has focused almost exclusively on right-wing populism, capital's power over the land has also spurred nonpartisan resistance. Financialization of forestland ownership in the United States has diversified how companies profit from the land, whether through carbon sequestration, conservation easements, wind tower leases, or mechanized logging. These new sources of profit, though, create fewer jobs than the traditional woods products industries. Based on more than a year of ethnographic research in a forested region of northern New England, I describe an anti-establishment politics spurred by opposition to one of these development projects, an electrical transmission corridor proposed by an international energy company. I argue that the resistance to this project is a response to ‘behind closed doors’ negotiations and the accumulation of power in the hands of a small number of energy companies, timberland owners, politicians, government agencies and environmental NGOs. Scholarship on the resistance to neoliberalism's effects on the rural United States should thus not be limited to a left/right populism framework.

Does increasing health care access reduce disability insurance caseloads? Evidence from the rural United States.

This paper leverages the expansion of the United States' Community Health Center program over the 21st century to investigate whether improved access to health care reduces disability insurance (DI) participation at the county level. I find that the introduction of a health center that specializes in mental health and substance abuse services is associated with a 0.09 to 0.40 percentage point reduction in working-age DI enrollment in rural counties. A cost-benefit analysis indicates that the money saved from reduced program participation can account for more than a third of the cost the federal government faces in funding well-targeted health care access initiatives.

Commentary: Pandemic Inequities: Refugees' Health in the Rural United States During COVID-19.

Commentary: Pandemic Inequities: Refugees' Health in the Rural United States During COVID-19.

Hepatopancreatic Surgery in the Rural United States: Variation in Outcomes at Critical Access Hospitals

BackgroundSixty million Americans live in rural America, with roughly 17.5% of the rural population being 65 y or older. Outcomes and costs of Medicare beneficiaries undergoing hepatopancreatic surgery at critical access hospitals (CAHs) are not known. Materials and MethodsMedicare files were used to identify patients who underwent hepatopancreatic resection. Outcomes were compared (CAHs versus non-CAHs). ResultsPatients undergoing hepatopancreatic surgery at non-CAHs versus CAHs had a similar comorbidity score (4 versus 5, P = 0.53). After adjusting for patient-level factors and procedure-specific volume, there was no difference in complication rate (adjusted odds ratio (aOR) 0.80, 95% confidence interval (CI) 0.52-1.24). The median cost of hospitalization was roughly $4000 less at CAHs than that at non-CAHs (P < 0.001). However, compared with patients undergoing surgery at non-CAHs, beneficiaries operated at CAHs had more than two times the odds of dying within 30 (aOR 2.45, 95% CI 1.42-4.2) and 90 d (aOR 2.28, 95% CI 1.4-3.71). ConclusionsOnly a small subset of Medicare beneficiaries underwent hepatic or pancreatic resection at a CAH. Despite similar complication rate, Medicare beneficiaries undergoing surgery at a CAH had more than two times the odds of dying within 30 and 90 d after surgery.

Rural representation of the surveillance, epidemiology, and end results database.

SEER data are widely used to study rural-urban disparities in cancer. However, no studies have directly assessed how well the rural areas covered by SEER represent the broader rural United States. Public data sources were used to calculate county level measures of sociodemographics, health behaviors, health access and all cause cancer incidence. Driving time from each census tract to nearest Commission on Cancer certified facility was calculated and analyzed in rural SEER and non-SEER areas. Rural SEER and non-SEER counties were similar with respect to the distribution of age, race, sex, poverty, health behaviors, provider density, and cancer screening. Overall cancer incidence was similar in rural SEER vs non-SEER counties. However, incidence for White, Hispanic, and Asian patients was higher in rural SEER vs non-SEER counties. Unadjusted median travel time was 53min (IQR 34-82) in rural SEER tracts and 54min (IQR 35-82) in rural non-SEER census tracts. Linear modeling showed shorter travel times across all levels of rurality in SEER vs non-SEER census tracts when controlling for region (Large Rural: 13.4min shorter in SEER areas 95% CI 9.1;17.6; Small Rural: 16.3min shorter 95% CI 9.1;23.6; Isolated Rural: 15.7min shorter 95% CI 9.9;21.6). The rural population covered by SEER data is comparable to the rural population in non-SEER areas. However, patients in rural SEER regions have shorter travel times to care than rural patients in non-SEER regions. This needs to be considered when using SEER-Medicare to study access to cancer care.

Health and Health Care of Sexual Minority Individuals in the Rural United States: A Systematic Review.

Lesser health care access and utilization in rural areas are associated with ruralurban health outcome disparities. While some work has examined similar disparities by sexual orientation, little has explicitly explored the combined influences of rural residence and lesbian, gay, and bisexual (LGB) status. This study aims to explore literature specific to rural LGB health care access and utilization, identify gaps, and suggest future research. Several databases were searched to identify studies specific to LGB health care access and utilization, and 18 articles were identified and divided into two categories: barriers and facilitators to health care access. Barriers included provider training, discrimination, distance and physical access, and fewer social supports. The data also indicated that sexual orientation disclosure is associated with better health care. Rural sexual minority individuals undergo health care access and utilization inequities, even in excess of their heterosexual rural peers that may be addressed with training and social interventions. Further research is warranted.

Coping With and Adapting to COVID-19 in Rural United States and Canada

Guidelines aimed at slowing the spread of COVID-19 resulted in major changes in people’s lives. A cross-sectional online survey, completed by 1,405 adults in Canada and the United States in June 2020, found respondents from rural areas/small towns reported better coping and adjustment (i.e., less use of substances for support), less personal impact, less life disruption, and fewer challenges with transportation and health care, than urban and suburban respondents. Those in rural areas were less likely to use the newspaper, but more likely to use social media, for information. Finally, rural respondents reported higher levels of support for their national leadership’s response to the pandemic. The needs and strengths of rural areas, as well as approaches to serve rural areas are discussed.

Addressing Health Disparities in the Rural United States: Advocacy as Caregiving among Community Health Workers and Promotores de Salud.

Rural populations in the United States are faced with a variety of health disparities that complicate access to care. Community health workers (CHWs) and their Spanish-speaking counterparts, promotores de salud, are well-equipped to address rural health access issues, provide education, and ultimately assuage these disparities. In this article, we compare community health workers in the states of Indiana and Texas, based on the results of two separate research studies, in order to (1) investigate the unique role of CHWs in rural communities and (2) understand how their advocacy efforts represent a central form of caregiving. Drawing on ethnographic, qualitative data—including interviews, photovoice, and participant observation—we analyze how CHWs connect structurally vulnerable clients in rural areas to resources, health education, and health and social services. Our primary contribution to existing scholarship on CHWs is the elaboration of advocacy as a form of caregiving to improve individual health outcomes as well as provoke structural change in the form of policy development. Finally, we describe how CHWs became especially critical in addressing disparities among rural populations in the wake of COVID-19, using their advocacy-as-caregiving role that was developed and well-established before the pandemic. These frontline workers are more vital than ever to address disparities and are a critical force in overcoming structural vulnerability and inequities in health in the United States.

A Systematic Review of Factors Impacting Suicide Risk Among Rural Adults in the United States.

Suicide rates continue to be significantly higher in rural compared to urban communities in the United States, with the suicide rate disparity continuing to grow since 1999. This systematic review synthesizes rural-specific factors related to increased suicide risk. OVID Medline, EMBASE, OVID PsycINFO, Web of Science, SocINDEX, Cochrane Library, and Google Scholar were searched for articles published after 2003 investigating rural adult suicide in the United States. Selection criteria were: (1) study participants > 18 years old; (2) included rural participants or communities; (3) included suicidal self-directed violence outcomes; (4) within the United States; (5) published after 2003; (6) presented peer-reviewed original data; (7) identified rural-specific risk or protective factors for suicide or barriers to treatment. Of the 1,058 records screened, 34 studies were included. The strength of evidence was relatively stronger for individual level factors including lethal means, alcohol and substance use. Access to firearms is strongly related to elevated rural US suicide rates, with substance use, economic stress, and behavioral health care utilization as additional individual level factors that may contribute to the disparity. At the community level, economic distress and access to care were commonly identified factors. Future research should better quantify how risk factors contribute to rural suicide and examine interdependence across social-ecological levels. Suicide prevention efforts for the rural United States must address access to lethal means, in particular the use of firearms, and navigate limited access to quality behavioral health care.

Authoritarian populism and emancipatory politics in the rural United States

• The Democratic Party's neoliberal turn alienated its working-class base. • A white-washed version of “the rural” drives ethno-nationalist populism in the USA. • Historical and contemporary cases of multiracial unity deserve greater attention. • Internal colonialism is key to analyzing racial formation and urban/rural divides. • Uncertainty, when recognized as a shared problem, can build solidarity.

Synergistic Disparities and Public Health Mitigation of COVID-19 in the Rural United States.

Public health emergencies expose social injustice and health disparities, resulting in calls to address their structural causes once the acute crisis has passed. The COVID-19 pandemic is highlighting and exacerbating global, national, and regional disparities in relation to the benefits and burdens of undertaking critical basic public health mitigation measures such as physical distancing. In the United States, attempts to address the COVID-19 pandemic are complicated by striking racial, economic, and geographic inequities. These synergistic inequities exist in both urban and rural areas but take on a particular character and impact in areas of rural poverty. Rural areas face a diverse set of structural challenges, including inadequate public health, clinical, and other infrastructure and economic precarity, hampering the ability of communities and individuals to implement mitigation measures. Public health ethics demands that personnel address both the tactical, real-time adjustment of typical mitigation tools to improve their effectiveness among the rural poor as well as the strategic, longer-term structural causes of health and social injustice that continue to disadvantage this population.