Rural US Communities Research Articles

Effect of Telehealth Extended Care for Maintenance of Weight Loss in Rural US Communities

Lifestyle interventions for obesity produce reductions in body weight that can decrease risk for diabetes and cardiovascular disease but are limited by suboptimal maintenance of lost weight and inadequate dissemination in low-resource communities. To evaluate the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System. This randomized clinical trial was conducted from October 21, 2013, to December 21, 2018, in Cooperative Extension Service offices of 14 counties in Florida. A total of 851 individuals were screened for participation; 220 individuals did not meet eligibility criteria, and 103 individuals declined to participate. Of 528 individuals who initiated a 4-month lifestyle intervention, 445 qualified for randomization. Data were analyzed from August 22 to October 21, 2019. Participants were randomly assigned to extended care delivered via individual or group telephone counseling or an education control program delivered via email. All participants received 18 modules with posttreatment recommendations for maintaining lost weight. In the telephone-based interventions, health coaches provided participants with 18 individual or group sessions focused on problem solving for obstacles to the maintenance of weight loss. The primary outcome was change in body weight from the conclusion of initial intervention (month 4) to final follow-up (month 22). An additional outcome was the proportion of participants achieving at least 10% body weight reduction at follow-up. Among 445 participants (mean [SD] age, 55.4 [10.2] years; 368 [82.7%] women; 329 [73.9%] white), 149 participants (33.5%) were randomized to individual telephone counseling, 143 participants (32.1%) were randomized to group telephone counseling, and 153 participants (34.4%) were randomized to the email education control. Mean (SD) baseline weight was 99.9 (14.6) kg, and mean (SD) weight loss after the initial intervention was 8.3 (4.9) kg. Mean weight regains at follow-up were 2.3 (95% credible interval [CrI], 1.2-3.4) kg in the individual telephone counseling group, 2.8 (95% CrI, 1.4-4.2) kg for the group telephone counseling group, and 4.1 (95% CrI, 3.1-5.0) kg for the education control group, with a significantly smaller weight regain observed in the individual telephone counseling group vs control group (posterior probability >.99). A larger proportion of participants in the individual telephone counseling group achieved at least 10% weight reductions (31.5% [95% CrI, 24.1%-40.0%]) than in the control group (19.1% [95% CrI, 14.1%-24.9%]) (posterior probability >.99). This randomized clinical trial found that providing extended care for obesity management in rural communities via individual telephone counseling decreased weight regain and increased the proportion of participants who sustained clinically meaningful weight losses. ClinicalTrials.gov Identifier: NCT02054624.

Feasibility of a low-cost hearing screening in rural Indiana

BackgroundHearing loss remains a neglected public health issue in the rural and agricultural communities in the United States and therefore, promotion of a low-cost hearing screening may be important for these underserved populations. The major objectives of our study were to assess feasibility of a low-cost telephone-administered hearing test in rural Indiana and to identify the challenges, barriers and viable implementation strategies associated with this test. Also, we evaluated whether a focus group session could change the hearing health attitude of rural residents.MethodsWe recruited 126 adults from six rural Indiana counties who participated in study activities in the following order: 1) a pre-focus group demographic, knowledge and attitude survey, 2) a focus group for discussing the feasibility of a telephone-administered hearing screening, 3) a post focus group attitude survey and 4) hearing was screened using an audiometer and self-assessment scale. These activities generated both qualitative and quantitative data, which were subsequently analyzed.ResultsHearing impairment was perceived as an important public health issue. Many participants expressed interests to try the low-cost National Hearing Test (NHT). However, participants recommended NHT to be facilitated by community organizations to provide access to landline phones. The focus group turned out to be an excellent awareness building activity producing significant improvement in hearing health attitudes. Comparison of self and audiometric evaluations indicated underestimation of hearing handicap in our rural study population.ConclusionsThe study results underscore the urgent need for an effective strategy to promote low-cost hearing screening in rural US communities.

Development and testing of a community audit tool to assess rural built environments: Inventories for Community Health Assessment in Rural Towns.

Rural populations face unique challenges to physical activity that are largely driven by environmental conditions. However, research on rural built environments and physical activity is limited by a paucity of rural-specific environmental assessment tools. The aim of this paper is to describe the development and testing of a rural assessment tool: Inventories for Community Health Assessment in Rural Towns (iCHART). The iCHART tool was developed in 2013 through a multistep process consisting of an extensive literature search to identify existing tools, an expert panel review, and pilot testing in five rural US communities. Tool items represent rural built environment features that influence active living and physical activity: community design, transportation infrastructure, safety, aesthetics, and recreational facilities. To assess reliability, field testing was performed in 26 rural communities across five states between July and November of 2014. Reliability between the research team and community testers was high among all testing communities (average percent agreement = 77%). Agreement was also high for intra-rater reliability (average kappa = 0.72) and inter-rater reliability (average percent agreement = 84%) among community testers. Findings suggest that the iCHART tool provides a reliable assessment of rural built environment features and can be used to inform the development of contextually-appropriate physical activity opportunities in rural communities.

Applying Global Perspectives on Fragility to Improve US Communities

Today, the greatest impacts on families stem from ongoing global conflicts and other natural or man-made disasters. Literature and multi-lingual research were examined and analyzed to determine fragility in rural and urban US communities with high immigrant populations, high poverty, and challenged social integration. Data came from international development and localized research. Literature review content was related to fragility, families emigrating to the US coming from those fragile states, and immigrants’ ability to adapt to new environments as evidenced in research analyses. Approaches that non-governmental, humanitarian and peace-building entities are taking to bridge research with application were also examined. A model of adaptive and culturally-relevant practices is offered as a logical way to address the effects of poverty and fragile conditions, and to move affected populations toward resilience.

Citizens' perceptions of police in rural US communities: a multilevel analysis of contextual, organisational and individual predictors

There has been little research on citizens' attitudes about policing in rural communities in the USA, and existing studies do not examine the effects of community characteristics on these attitudes. We extend this work theoretically and analytically by considering the effects of community context, police organisation and individual characteristics on attitudes about police. Using data for a large sample of citizens residing in 98 small towns in Iowa, we employed multilevel ordered logistic regression techniques to model citizens' rating of police protection and degree of trust in the police. At the community level, social disorganisation was negatively associated with both outcome variables, and social integration was positively related to trust in the police. Town police departments were viewed more favourably than county sheriff's offices for both police protection and trust. Individual-level perceptions of social integration and community safety were positively related to both outcome variables. Respondents' sociodemographic characteristics had relatively few significant effects. A statistical interaction between social disorganisation and individual perceptions of social integration was observed for trust in the police, with higher levels of perceived social integration attenuating the negative effect of social disorganisation. In sum, contextual, organisational and individual predictors all had important effects on attitudes about police in this study. These findings demonstrate that theories emphasising community context are essential to a more complete understanding of crime-related attitudes in rural communities.

Regional PM2.5 and asthma morbidity in an agricultural community: A panel study

BackgroundElevated pediatric asthma morbidity has been observed in rural US communities, but the role of the ambient environment in exacerbating rural asthma is poorly understood. ObjectivesTo investigate associations between particulate matter less than 2.5μm in diameter (PM2.5) and pediatric asthma exacerbations in an agricultural community of Washington State. MethodsSchool-aged children with asthma (n=58) were followed for up to 25 months with repeated measures of respiratory health. Asthma symptoms and quick-relief medication use were assessed biweekly through phone administered surveys (n=2023 interviews). In addition, subjects used home peak flow meters on a daily basis to measure forced expiratory volume in one second (FEV1) (n=7830 measurements). Regional PM2.5 was measured at a single air monitor located centrally in the study region. To assess relationships between PM2.5 and these outcomes we used linear regression with generalized estimating equations, adjusting for meteorological and temporal confounders. Effect modification by atopy was explored as well. ResultsAn interquartile increase (IQR) in weekly PM2.5 of 6.7μg/m3 was associated with an increase in reported asthma symptoms Specific symptoms including wheezing, limitation of activities, and nighttime waking displayed the strongest associations. FEV1 as a percent of predicted decreased by 0.9% (95%CI: −1.8, 0.0) for an IQR increase in PM2.5 one day prior, and by 1.4% (95%CI: −2.7, −0.2) when restricted to children with atopic asthma. ConclusionsThis study provides evidence that PM2.5 in an agricultural setting contributes to elevated asthma morbidity. Further work on identifying and mitigating sources of PM2.5 in the area is warranted.

Optimism for new business survival in rural communities: an institutional perspective

This study uses institutional theory to examine the relationship between rural community norms and optimism for new firm survival. A survey of 1161 residents and business owners in 32 rural US communities explored community-wide attitudes toward change and norms related to community and local business sector symbolic and performative actions and their influence on local residents’ optimism about prospects for success of new businesses. Multiple regression analysis revealed that institutional norms supporting change and reflecting positive attitudes regarding residents’ and business owners’ actions in the task environments are positively related to community optimism about new firm survival. Evidence also supports differential effects of population size on norms related to openness to change and retailer performative actions. Findings suggest that the rural community institutional environment may have an influence on efforts to attract and retain new businesses in rural communities.

Mad Men in Bib Overalls: Media’s Horrification and Pornification of Rural Culture

The media play a key role in stereotyping as “ignorant and uncouth hillbillies” people who live in rural US communities. As well, since the early 1970s, popular films frequently portray rural areas as dangerous locations, places where urban people are at high risk of being savagely killed and tortured by demented, in-bred locals without conscience or constraint. Further, with the advent of the Internet, rural women continue to be depicted in a degrading, highly sexualized manner and “gonzo” pornographic videos of them are widely and freely accessible. Informed by feminist and cultural criminological modes of inquiry, this paper presents some exploratory research on rural horror films and pornographic videos. A key argument is that with the help of new information technologies, these media are normalized, mainstreamed, and contribute to the horrification/pornification of rural culture, and by doing so, mask the real issues about crime, violence, and gender relations in the rural context.

Food group consumption and its association with BMI z‐score and socioeconomic characteristics in rural school‐aged children

U.S. children's compliance with dietary recommendations varies by age, gender, and socioeconomic and weight status. We analyzed data from 1273 children (grades 1–6) participating in the Creating Healthy, Active and Nourishing Growing‐up Environments (CHANGE) study, an obesity‐prevention intervention in eight rural US communities. Children's intakes of fruits, vegetables, whole grains, protein foods and dairy were assessed using the Block Food Screener for ages 2–17 y. General linear models were used to calculate adjusted prevalence of meeting 50% of recommended whole‐grain servings and 100% of recommended servings for the other groups and to study the association between covering recommendations and weight. Prevalence of meeting dietary recommendations decreased across age groups for all food groups except fruits. Prevalence of meeting the fruit recommendations was lower in boys than girls. Hispanic children were more likely to consume recommended fruit and dairy servings, compared to black and white children, and whole grains compared to white children. BMI z‐score and prevalence of overweight and obesity was lower in children meeting recommendations for all food groups compared to children who met no recommendations (1.13 vs.0.77, P=0.02 and 39 vs. 61%, P < 0.001, respectively). Adhering to dietary recommendations varied by age, gender, race and weight status in this population of rural children.Support was provided by Save the Children's U.S. Programs.

Community Matters: Successful Entrepreneurship in Remote Rural US Locations

Entrepreneurs in remote rural towns face unique challenges. These towns have fewer people, with less income, making fewer purchases. Businesses also have problems associated with long distances and isolation. However, these general circumstances cannot explain the variation in success among rural entrepreneurs. Due to the tendency in previous studies to aggregate data on rural businesses, the situation of entrepreneurs in remote rural US communities is understudied. The purpose of this study is to examine the correlates of successful entrepreneurs in these remote areas. The findings indicate that entrepreneurs who start businesses to provide income and flexibility for their family have more perceived success than those motivated by a desire for great wealth and the wish to challenge themselves. Entrepreneurs in high bridging social capital towns were also more successful. Community bridging social capital may enhance entrepreneurs' success by helping to retain and attract skilled labour, reducing costs, providing access to capital and engendering resident customer loyalty.

Divorce as an Influence in Return Migration to Rural Areas

ABSTRACTThis qualitative study focuses on individuals who moved back to rural US communities in relatively isolated areas with modest levels of natural amenities. Open‐ended interviews at high school reunions revealed that a subset of return migration was driven by marital separation and divorce. This research sets out to explore why after divorce people return to rural areas, despite what are often limited economic opportunities. Findings suggest that both people and place shape return migration decisions after divorce: an individual's functional and emotional support networks, provided by people, work with the physical and affective attributes offered by place. Return migration to rural areas after divorce can be seen as a strategy to adapt to post‐divorce changes and to cope with the trauma and vulnerabilities that can accompany divorce. Copyright © 2012 John Wiley & Sons, Ltd.

Whole grain consumption is inversely associated with BMI Z-score in rural school-aged children.

To examine the relationship between intake of whole grains and BMI Z-score in rural children. General linear models and logistic regression were used to examine the cross-sectional associations between whole grain intake and BMI Z-score, prevalence and odds ratios of overweight and obesity. Dietary intake was assessed using the Block Food Screener for ages 2-17 years. Children were classified into three categories according to servings of whole grain intake: <1·0 serving/d, 1·0-1·5 servings/d and >1·5 servings/d. The CHANGE (Creating Healthy, Active and Nurturing Growing-up Environments) study, an obesity prevention intervention in elementary schools in eight rural US communities in California, Mississippi, Kentucky and South Carolina. Seven hundred and ninety-two children attending 3rd-6th grade. After adjusting for age, sex, race/ethnicity, physical activity and state of residence, whole grain intake was inversely associated with BMI Z-score (0·90 v. 0·61 in the lowest v. the highest whole grain intake category; P trend = 0·01). Children who consumed >1·5 servings of whole grains/d had a 40 % lower risk of being obese (OR = 0·60; 95 % CI 0·38, 0·95, P = 0·02) compared with children who consumed <1·0 serving/d. Further adjustment for potential dietary predictors of body weight (fruit, vegetable and dairy intakes) did not change the observed associations. Increasing the intake of whole grains as part of an overall healthy lifestyle may be beneficial for children to achieve and maintain a healthy weight.

Factors determining inshopping in rural US communities

PurposeThe purpose of this study is to determine factors influencing rural consumers' inshopping behaviours and to examine rural retailers' perceptions of the current rural retailing environment.Design/methodology/approachThis study was comprised of two phases. In Phase 1, consumer surveys were conducted in three rural US communities. In Phase 2, in‐depth interviews with retailers selected from the same communities were conducted.FindingsThe findings of the consumer surveys supported all hypothesised relationships, except the direct effect of community attachment on inshopping intention. The findings of the retailer interviews provided useful insights as to the challenges rural retailers are currently facing.Research limitations/implicationsThe findings have implications for both retailers and community leaders in rural places who wish to improve their understanding of the challenges and opportunities rural retailers face and subsequently develop strategies to promote inshopping behaviours.Originality/valueThis study examined both consumers and retailers in the context of rural retailing. Thus, the findings provide a more complete picture of the current retail industry in rural communities.

Explaining place-based colorectal cancer health disparities: Evidence from a rural context

A growing body of work examines geographical setting as a source of health disparity, hypothesizing individual as well as larger, environmental sources of risk. However, mechanisms by which this influence operates, especially in rural settings, are not well understood. This study investigates the problem of colorectal cancer in a rural US community through the lens of geographical setting. Statewide maps of colorectal cancer burdens show a place-based disparity in colorectal cancer in the region surrounding a small, diverse Iowa community. Within a research partnership framework, we use these maps to engage community residents in discussions of high colorectal cancer rates. We ask how a rural community experiencing higher than expected rates of colorectal cancer late-stage diagnosis and mortality perceives and explains their increased risk, interpreting available epidemiological evidence based on their lived experience. We use concept mapping to organize these perceptions and situate our findings in the context of previous work. Our findings reveal a complex understanding of risk that should be taken into account in crafting effective public health interventions and messages. Our work informs the growing literature on how context influences individual experiences of health problems, with specific relevance for rural populations.

Targeting the Local: Policing Clandestine Methamphetamine Production in a Rural US Community

AbstractIn the United States, state-based efforts to curtail the spread of methamphetamine (“meth”) have targeted domestic producers through heightened regulation of precursor chemicals used in the clandestine meth-production process. This article examines the impact of these efforts on the exercise of police power in a rural community affected by methamphetamine. As the author shows, the targeting of local meth production has incorporated residents of rural communities into the policing process by variously encouraging and requiring them to adopt a new way of perceiving the local landscape, centred around methamphetamine. Under the new legislation, previously benign objects such as cold medicine, batteries, and drain cleaner have been re-signified as objects with criminal potential that residents of rural communities are called upon to police. This has led to the expansion of police power within and beyond the formal domains of law enforcement. Through the targeting of local production, civic volunteers, pharmacists, retail clerks, natural resource officers, and others have been drawn into the policing of the meth problem. This reveals a key dynamic in the localization of police power: as police power is localized, the local is reimagined in terms of police power.

Development of the rural active living assessment tools: Measuring rural environments

Objective Develop rural-specific assessment tools to be used by researchers and practitioners to measure the activity-friendliness of rural communities. Method The tools were created through a mixed-methods investigation into the determinants of physical activity among rural populations. This informed the development of a conceptual framework defining activity-friendly rural environments. Questions were generated to reflect applicable existing urban-based variables and rural conceptual model elements. Pilot testing was conducted in seven rural US communities during the fall of 2008. Inter-rater reliability was assessed. Results The Rural Active Living Assessment (RALA) Tools include three components: Town-Wide (18 town characteristic questions, and inventory of 15 recreational amenities), Program and Policy (20 questions), and Street Segment (28 questions). We found that the Town-wide and Program and Policy tools were feasible for community members to implement. The observed agreement and κ statistic across all items for the Street Segment Assessment were substantial (91.9% and 0.78, respectively). Conclusions The RALA Tools were shown to be feasible and reliability was supported. They assess features believed to be supportive of active living in rural environments, offer users a resource to assess rural environments for activity-friendliness, and may also inform the design of interventions to help rural communities become more active and healthy.

Rural Interhospital Transfer of ST-Elevation Myocardial Infarction Patients for Percutaneous Coronary Revascularization

In Europe, interhospital transfer of ST-elevation myocardial infarction (STEMI) patients for primary percutaneous coronary intervention (PCI) from non-PCI-capable (STEMI-referral) to PCI-capable (STEMI-accepting) facilities has been shown to be a superior reperfusion strategy compared with on-site fibrinolysis. The feasibility of such programs in the United States remains poorly defined. We describe an observational cohort of 230 consecutive presumed STEMI patients who underwent interhospital transfer between January 2005 and March 2007 among 6 STEMI-referral and 2 STEMI-accepting hospitals in rural central Illinois. A standard treatment protocol using rapid interhospital transfer for primary PCI or rescue PCI after full-dose intravenous fibrinolysis (in event of unanticipated transfer delays) was initiated by the STEMI-referral emergency department physician. Three time intervals were evaluated: STEMI-referral care (door 1 to departure), transport time (door 1 departure to STEMI-accepting hospital arrival [door 2]), and STEMI-accepting hospital care (door 2 to balloon). Primary PCI was performed in 165 STEMI-confirmed patients (87.7%), whereas fibrinolysis was required in 16 patients (8.5%), with 56% undergoing rescue PCI. The median door 1-to-departure time was 46 minutes (25th and 75th percentiles, 32 and 62 minutes); approximately two thirds of this delay was attributable to the wait for transport arrival and departure. The transport and door 2-to-balloon times were 29 minutes (25th and 75th percentiles, 25 and 35 minutes) and 35 minutes (25th and 75th percentiles, 32 and 46 minutes), respectively. The door 1-to-balloon time was 117 minutes (25th and 75th percentiles, 98 and 137 minutes), with 12.2% and 58% of patients achieving a time of < or = 90 and < or = 120 minutes, respectively. No adverse clinical events occurred during interhospital transport. In rural US communities, emergency department physician-initiated interhospital transfer of STEMI patients for primary or rescue PCI is feasible and was safely executed with achievement of timely reperfusion when performed within coordinated healthcare networks.

Diabetes meanings a mong those without diabetes: explanatory models of immigrant Latinos in rural North Carolina

The prevalence of type 2 diabetes is increasing in the United States, particularly among minority individuals. Primary prevention programs for diabetes must be designed to address the beliefs of the populations they target. Little research has investigated the beliefs of those who do not have diabetes. This analysis uses in-depth interviews collected from Latino immigrants, not diagnosed with diabetes, living in a rural US community. Structured by the explanatory models [EM] of Illness framework, this analysis delineates the EMs of diabetes in this community. A significant number of the participants had little knowledge and few beliefs about diabetes. The EMs of those with knowledge of diabetes were varied, but several beliefs were widely held: (a) diabetes is a serious disease that is based on heredity or is inherent in all persons, (b) diabetes can result from several factors, including strong emotions and lifestyle characteristics (an unhealthy diet, not taking care of oneself), (c) beliefs about strong emotion and the importance of blood are related to diabetes causes, symptoms and treatment, and (d) a major and undesirable outcome of diabetes is weight loss. These results provide information for the design of health programs for the prevention of type 2 diabetes.

Segregation analysis of blood pressure and body mass index in a rural US community.

To assess evidence for a gene with large effect on systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI), we conducted segregation analyses on 261 nuclear families collected from a rural Caucasian community in Michigan. The families were ascertained through a hypertensive proband. Each phenotype was adjusted for significant covariate effects (e.g., gender and age). We used class D regressive models to conduct the segregation analyses. Our analysis results support the segregation of a major gene for BMI, but not for SBP or DBP. A recessive locus effect provided the best explanation for BMI where approximately 43% of the variance of BMI was due to this gene.

Community-acquired methicillin-resistant Staphylococcus aureus in a rural American Indian community.

Until recently, methicillin-resistant Staphylococcus aureus (MRSA) infections have been acquired primarily in nosocomial settings. Four recent deaths due to MRSA infection in previously healthy children in the Midwest suggest that serious MRSA infections can be acquired in the community in rural as well as urban locations. To document the occurrence of community-acquired MRSA infections and evaluate risk factors for community-acquired MRSA infection compared with methicillin-susceptible S aureus (MSSA) infection. Retrospective cohort study with medical record review. Indian Health Service facility in a rural midwestern American Indian community. Patients whose medical records indicated laboratory-confirmed S aureus infection diagnosed during 1997. Proportion of MRSA infections classified as community acquired based on standardized criteria; risk factors for community-acquired MRSA infection compared with those for community-acquired MSSA infection; and relatedness of MRSA strains, determined by pulsed-field gel electrophoresis (PFGE). Of 112 S aureus isolates, 62 (55%) were MRSA and 50 (45%) were MSSA. Forty-six (74%) of the 62 MRSA infections were classified as community acquired. Risk factors for community-acquired MRSA infections were not significantly different from those for community-acquired MSSA. Pulsed-field gel electrophoresis subtyping indicated that 34 (89%) of 38 community-acquired MRSA isolates were clonally related and distinct from nosocomial MRSA isolates found in the region. Community-acquired MRSA may have replaced community-acquired MSSA as the dominant strain in this community. Antimicrobial susceptibility patterns and PFGE subtyping support the finding that MRSA is circulating beyond nosocomial settings in this and possibly other rural US communities.