Rural Status Research Articles

Association between BMI and age at menarche or spermarche among both sexes: Findings from six successive national surveys in China.

To explore trends of the association between body mass index (BMI) and age at menarche or spermarche and its urban-rural disparities from 1995 to 2019. A total of 912 753 children and adolescents - including 519 940 9-18 years old girls and 392 813 11-18 years old boys - were involved in six successive cross-sectional surveys conducted across 30 provinces in China from 1995 to 2019. Data on menarche and spermarche was collected using the status quo method, where same-gender physicians conducted face-to-face interviews to determine if children and adolescents had experienced their first menstrual cycle or ejaculation (yes/no). The median age at menarche or spermarche was estimated by probit analysis. Anthropometric measurements measured the height and weight of the study subjects. Children and adolescents were classified into thinness, normal range of weight, overweight, and obesity. t test was used to compare the differences in BMI between premenarchal and postmenarchal girls or prespermarcheal and postspermarcheal boys. Logistic regression was used to explore the associations between BMI/nutritional status and menarche or spermarche stratified by urban or rural residency status. From 1995 to 2019, BMI in all age groups growth over time, and the values of BMI among children and adolescents under 15 who had menarche or spermarche were more significant than those without menarche or spermarche. In 2019, for girls, thinness was associated with delayed menarche (odds ratio (OR) = 0.26; 95% confidence interval (CI) = 0.24-0.28), while overweight (OR = 1.99; 95% CI = 1.85-2.14) and obesity (OR = 2.20; 95% CI = 1.92-2.53) was associated with advanced menarche. For boys, thinness was associated with delayed spermarche (OR = 0.71; 95% CI = 0.65-0.78), overweight was associated with advanced spermarche (OR = 1.08; 95% CI = 1.01-1.15) while obesity had no association with spermarche. The OR between BMI and menarche in 1995 was 1.35 (95% CI = 1.33-1.37), which decreased to 1.19 (95% CI = 1.18-1.20) by 2019. The OR between BMI and spermarche in 1995 was 1.10 (95% CI = 1.09-1.11), which decreased to 1.02 (95% CI = 1.02-1.03) by 2019. The trends by urban-rural stratification were consistent with the total sample. We have established a dose-response relationship between BMI and menarche in girls, whereas the association appears to be nonlinear in boys, and the associations were diminishing. Similar findings were observed in both urban and rural areas. Considering the dual adverse effects of obesity and early puberty on health, the results of this study suggest that sexual health education should be strengthened, especially among obese girls. Further research on the influencing factors and biological mechanisms of early puberty will be beneficial.

Exploring biorepository donation patterns, experiences, and recommendations: a mixed-methods study among Appalachian adults enrolled in a sugary drink reduction program.

Under-represented subgroups in biomarker research linked to behavioral health trials may impact the promise of precision health. This mixed methods study examines biorepository donations across an Appalachian sample enrolled in a sugary drink reduction intervention trial. Participants enrolled in the behavioral trial were asked to join an optional biomarker study and were tracked for enrollment and biospecimen returns (stool and/or buccal sample). At 6 months, participants completed a summative interview on decision-making process, experiences collecting samples, and recommendations to encourage biospecimen donation. Return rates were analyzed across demographics (i.e., age, gender, race, education, income, health literacy status, and rurality status) using chi-squares. Qualitative data were content coded with differences compared by biomarker study enrollment and donation choices. Of the 249 invited participants, 171 (61%) enrolled, and 63% (n = 157) returned buccal samples and 49% (n = 122) returned stool samples. Metro residing participants were significantly more likely (56%) to return stool samples compared to non-metro (39%) counterparts [x2(1) = 6.61; p = 0.01]. Buccal sample return had a similar trend, 67 and 57%, respectively for metro vs. non-metro [x2(1) = 2.84; p = 0.09]. An additional trend indicated that older (≥40 years) participants were more likely (55%) to donate stool samples than younger (43%) participants [x2(1) = 3.39; p = 0.07]. No other demographics were significantly associated with biospecimen return. Qualitative data indicated that societal (66-81%) and personal (41-51%) benefits were the most reported reasons for deciding to donate one or both samples, whereas mistrust (3-11%) and negative perceptions of the collection process (44-71%) were cited the most by those who declined one or both samples. Clear instructions (60%) and simple collection kits (73%) were donation facilitators while challenges included difficult stool collection kits (16%) and inconveniently located FedEx centers (16%). Recommendations to encourage future biorepository donation were to clarify benefits to science and others (58%), provide commensurate incentives (25%), explain purpose (19%) and privacy protections (20%), and assure ease in sample collection (19%). Study findings suggest the need for biomarker research awareness campaigns. Researchers planning for future biomarker studies in medically underserved regions, like Appalachia, may be able to apply findings to optimize enrollment.

Recruitment of Hard-To-Reach Populations in Randomized Controlled Trials Using Medical Students and Electronic Con-sents

Viral hepatitis is concentrated in populations with low healthcare system engagement, including non-white, rural, non-English speaking, and low socioeconomic status persons. Recruiting these participants for clinical trials has immense implications for trial feasibility and generalizability. Through the example of a trial delivering a behavioral intervention to patients with hepatitis C virus (HCV) in a network of medical student-run clinics, we describe the implementation of a student-run HCV testing program in the community and describe novel strategies to improve the recruitment of hard-to-reach participants using medical student counselors and electronic consents.

Estimation of cause-specific mortality in Rakai, Uganda, using verbal autopsy 1999-2019

ABSTRACT Background There are scant data on the causes of adult deaths in sub-Saharan Africa. We estimated the level and trends in adult mortality, overall and by different causes, in rural Rakai, Uganda, by age, sex, and HIV status. Objectives To estimate and analyse adult cause-specific mortality trends in Rakai, Uganda. Methodology Mortality information by cause, age, sex, and HIV status was recorded in the Rakai Community Cohort study using verbal autopsy interviews, HIV serosurveys, and residency data. We estimated the average number of years lived in adulthood. Using demographic decomposition methods, we estimated the contribution of each cause of death to adult mortality based on the average number of years lived in adulthood. Results Between 1999 and 2019, 63082 adults (15–60 years) were censused, with 1670 deaths registered. Of these, 1656 (99.2%) had completed cause of death data from verbal autopsy. The crude adult death rate was 5.60 (95% confidence interval (CI): 5.33–5.87) per 1000 person-years of observation (pyo). The crude death rate decreased from 11.41 (95% CI: 10.61–12.28) to 3.27 (95% CI: 2.89–3.68) per 1000 pyo between 1999–2004 and 2015–2019. The average number of years lived in adulthood increased in people living with HIV and decreased in HIV-negative individuals between 2000 and 2019. Communicable diseases, primarily HIV and Malaria, had the biggest decreases, which improved the average number of years lived by approximately extra 12 years of life in females and 6 years in males. There were increases in deaths due to non-communicable diseases and external causes, which reduced the average number of years lived in adulthood by 2.0 years and 1.5 years in females and males, respectively. Conclusion There has been a significant decline in overall mortality from 1999 to 2019, with the greatest decline seen in people living with HIV since the availability of antiretroviral therapy in 2004. By 2020, the predominant causes of death among females were non-communicable diseases, with external causes of death dominating in males.

Association of uninsured status and rurality with risk of financial toxicity after pediatric trauma

BackgroundPediatric traumatic injury is associated with long-term morbidity as well as substantial economic burden. Prior work has labeled the catastrophic out-of-pocket medical expenses borne by patients as financial toxicity. We hypothesized uninsured rural patients to be vulnerable to exorbitant costs and thus at greatest risk of financial toxicity. MethodsPediatric patients (<18 years) experiencing traumatic injury were identified in the 2016–2019 National Inpatient Sample. Patients were considered to be at risk of financial toxicity if their hospitalization cost exceeded 40% of post-subsistence income. Individual family income was computed using a gamma distribution probability density function with parameters derived from publicly available US Census Bureau data, in accordance with prior work. A multivariable logistic regression was developed to assess factors associated with risk of financial toxicity. ResultsOf an estimated 225,265 children identified for study, 34,395 (15.3%) were Rural. Rural patients were more likely to experience risk of financial toxicity (29.1 vs 22.2%, P < .001) compared to Urban patients. After adjustment, rurality (reference: urban status; adjusted odds ratio 1.45, 95% confidence interval 1.36–1.55) and uninsured status (reference: private; adjusted odds ratio 1.85, 95% confidence interval 1.67–2.05) remained linked to increased odds of risk of financial toxicity. Specifically among those with private insurance, Rural patients experienced markedly higher predicted risk of financial toxicity, relative to Urban. ConclusionOur findings suggest a complex interplay between rural status and insurance type in the prediction of risk of financial toxicity after pediatric trauma. To target policy interventions, future studies should characterize the patients and communities at greatest risk of financial devastation among rural pediatric trauma patients.

An Analysis of the Characteristics and Trends in Practicing Plastic Surgeons in California.

Studies suggest an increasing trend of plastic surgeons choosing private practice after training, with up to 90% pursuing private practice without future fellowships.1 Previous data showed that 66.7% of graduates from plastic surgery residency programs chose to pursue private practice without future fellowship, while more recent studies estimate this statistic has risen close to 90%.1,2 The literature has yet to characterize the current plastic surgery workforce and changes in its composition over time. This study aims to analyze the characteristics and training of plastic surgeons in California through a comparative study with general surgeons. Surgeon demographics were extracted from the Centers for Medicare and Medicaid Services open database. Urban/rural classification and academic affiliation were crosslinked from the Inpatient Prospective System database and sole proprietorship status was cross-linked from the NPI Registry. Summary statistics and logistic regressions with chi-squared analysis were analyzed using STATA/MP17. Our analysis consisted of 3871 plastic and general surgeons in California. Compared to general surgeons, plastic surgeons were less likely to be females (P < 0.000), and more likely to be sole proprietors (P < 0.000), and affiliated with a teaching hospital (P < 0.005). There was no statistically significant difference in the percentage of rural-practicing plastic and general surgeons (P = 0.590). More recent plastic surgery graduates were more likely to be affiliated with an academic hospital (P < 0.0000). The composition of females significantly increased from the older graduated cohort to the most recent one. There was no significant difference in sole proprietorship and rural practice status between the oldest and youngest graduating cohorts. Although the California plastic surgery workforce is gaining female plastic surgeons and shifting to academic institutions, significant progress in serving rural communities is yet to be made. Our study suggests that there may be a shift in the trend of plastic surgeons opting for private practice, possibly driven by a desire for more stable positions in academia. Continued improvement in diversity and training of future plastic surgeons is needed to alleviate the rural care gap.

Assessment of Primary Laboratory Facilities for Rural Health Care Preparedness in Osmanabad District, India

Government of India has provided Indian Public Health Standards to improve rural health care services and health status, but still rural laboratory is a cause of concern. This study is performed to understand the laboratory facility-level gaps that need to be addressed to improve the public primary health centres (PHCs) present in rural areas. The laboratory assessment is performed for governance, financing, resources and services, and results are validated with the PHC laboratory performance. The current assessment shows critical gaps in the facilities regarding governance, services, resources and financing required for the laboratory services at the rural primary health care level. Governance and services need to be strengthened the most, followed with sustained availability of resources and financing. Poor health status in rural areas necessitates public health response based on health systems. Therefore, health system preparedness in the form of laboratory services is essential in primary health care facilities.

Rural Households' Demand Status for Mitigation of Prosopis juliflora (Sw.) DC Invasion and Its Determinant Factors in Ethiopia: Empirical Evidence from Afar National Regional State.

Ethiopia is among the world's poorest nations, and its economy is growing extremely slowly; thus, the government's budget to manage environmental amenities is not always sufficient. Thus, for the provision of environmental management services such as the eradication of Prosopis juliflora, the participation of local households and other stakeholders is crucial. This study is therefore initiated with the objective of assessing rural households' demands for mitigating Prosopis juliflora invasion in the Afar Region of Ethiopia. A multistage sampling technique was employed to obtain the 313 sample rural households that were used in the analysis, and those sample households were selected randomly and independently from the Amibara and Awash Fentale districts of Afar National Regional State, Ethiopia. In doing this, a seemingly unrelated bivariate probit model was used to determine factors affecting rural households' demands for mitigating Prosopis juliflora invasion. Consequently, as per the inferential statistical results, there was a significant mean/percentage difference between willing and nonwilling households for the hypothesized variables, except for some variables such as farm experience; years lived in the area, distance from the market, and dependency ratio. Furthermore, the seemingly unrelated bivariate probit model result indicates that sex, family size, tenure security, livestock holding, frequency of extension contact, and years lived in the area were important factors influencing the willingness to participate in Prosopis juliflora management practices positively, whereas age, off-farm/nonincome, and bid value affected willingness to pay negatively and significantly. Hence, to improve the participation level of households, policymakers should target these variables.

Rural household vulnerability and COVID-19: Evidence from India.

The coronavirus disease 2019 (COVID-19) pandemic has affected vulnerable households' livelihoods in developing countries. Using high-frequency phone survey data from the World Bank, we assess rural Indian households' vulnerability and poverty status during the pandemic. Results reveal that over three-fifths of Indian rural households are vulnerable to poverty in the context of COVID-19, despite India's evident progress in mitigating poverty in the pre-pandemic era. Poverty plays a major role in accounting for variations in household vulnerability; however, the impact of risks on household welfare is not negligible. On average, households with more members, older household heads, and more outmigrants are more vulnerable to poverty during the pandemic. The impacts of the gender of the household head, access to masks, consumption loans, and COVID-related information are nevertheless insignificant. Results stress the urgent necessity of deploying concerted interventions to strengthen household vulnerability in rural India.

Estimating the Impact of Rural Hukou Status on Earnings for College Graduates in China

Abstract A growing body of literature explores the effect of higher education on the urban–rural divide in China. Despite an increasing number of rural students gaining access to college, little is known about their performance in college or their job prospects after graduation. Using nationally representative data from over 40,000 urban and rural college students, we examine rural students’ college performance and estimate the impact of rural status on students’ first job wages in comparison to their urban peers. Our results indicate that once accepted into college, rural students perform equally as well, if not better, than their urban counterparts. Additionally, we discovered that rural students earn a 6.2 per cent wage premium compared to their urban counterparts in their first job after graduation. Our findings suggest the importance of expanding access to higher education for rural students, as it appears to serve as an equalizer between urban and rural students despite their significantly different backgrounds.

Tobacco Quitline utilization compared with cigarette smoking prevalence in Virginia across rurality and Appalachian Status, 2011–2019

IntroductionWhile cigarette smoking rates have declined, rural and Appalachian populations in the United States have not seen similar decreases. Quitline programs are promising strategies in reducing disparities in these areas, but research on their usage is limited. MethodsWe employed Small Area Estimation on the Virginia Behavioral Risk Factor Surveillance System (2011–2019) to estimate county-level smoking prevalence and utilized The Quit Now Virginia Quitline data (2011–2019) to estimate Quitline users. We analyzed differences in Quitline utilization by rurality and Appalachian status using statistical t-tests. Stepwise regression assessed the absolute estimate of county features, including poverty rate, tobacco retailer density, physician availability, coal mining industry, and tobacco agriculture, on Quitline usage. ResultsWhile the average smoking rate overall was 15.3 %, only 7.4 % of smokers accessed Quitline services from 2011 to 2019. Appalachian regions exhibited higher smoking rates (20.9 %) and lower quitline usage (4.8 %) compared to non-Appalachian areas (14 % smoking prevalence, 8 % quitline usage). Rural regions had higher smoking prevalence (19.0 %) than urban areas (12.9 %), but no significant difference in Quitline utilization (7.6 % vs. 7.2 %, p = 0.7). Stepwise regression revealed counties with more tobacco agriculture had 3.2 % (p = 0.04) lower Quitline utilization. Also, more physicians availability in the county was associated with 3.9 % higher Quitline usage (p = 0.03) and Appalachian counties exhibited a 3.6 % lower Quitline usage rate compared to non-Appalachian counties. ConclusionA significant gap exists between cigarette smoking prevalence and Quitline utilization, particularly in underserved rural and Appalachian areas, despite no clear barriers to accessing this remote cessation resource. ImplicationThe study underscores persistent disparities in smoking rates, with rural and Appalachian regions in the United States facing higher smoking prevalence and limited utilization of Quitline services. Despite no clear barriers to access, the gap between smoking prevalence and Quitline usage remains significant, particularly in underserved areas. Tailoring interventions to address regional disparities and factors like tobacco agriculture and physician availability is essential to reduce smoking rates and improve Quitline utilization in these communities.

Association of rurality with short-term outcomes of peripheral vascular trauma

BackgroundPeripheral vascular trauma is a major contributing factor to long-term disability and mortality among patients with traumatic injuries. However, an analysis focusing on individuals at a high risk of experiencing limb loss due to rural and urban peripheral vascular trauma is lacking. MethodThis was a retrospective analysis of the 2016 to 2020 Nationwide Readmissions Database. Patients (≥18 years) undergoing open or endovascular procedures after admission for peripheral vascular trauma were identified using the 2016 to 2020 Nationwide Readmissions Database. Patients from rural regions were considered Rural, whereas the remainder comprised Urban. The primary outcome of the study was primary amputation. Multivariable regression models were developed to evaluate rurality with outcomes of interest. ResultsOf 29,083 patients, 4,486 (15.6%) were Rural. Rural were older (41 [28–59] vs 37 [27–54] years, P < .001), with a similar distribution of female sex (23.0 vs 21.3%, P = .09) and transfers from other facilities (2.8 vs 2.5%, P = .34). After adjustment, Rural status was not associated with the odds of mortality (P = .82), with urban as reference. Rural status was, however, associated with greater odds of limb amputation (adjusted odds ratio 1.85, 95% confidence interval 1.47–2.32) and reduced index hospitalization cost by $7,100 (95% confidence interval $3,500–10,800). Additionally, compared to patients from urban locations, rurality was associated with similar odds of non-home discharge and 30-day readmission. Over the study period, the marginal effect of rurality on the risk-adjusted rates of amputation significantly increased (P < .001). ConclusionPatients who undergo peripheral vascular trauma management in rural areas appear to increasingly exhibit a higher likelihood of amputation, with lower incremental costs and a lower risk of 30-day readmission. These findings underscore disparities in access to optimal trauma vascular care as well as limited resources in rural regions.

Neurological Care within the Indian Health Service.

American Indians and Alaska Natives (AI/AN) are the Indigenous peoples of the United States. According to the U.S. Census Bureau, approximately 9.7 million people self-identified as AI/AN (alone or in combination with other races), representing 2.9% of the total U.S. population. These people represent diverse groups of discrete Tribes, each with their language, culture, and geographic home. As part of the conquest and settlement of North America, some Indigenous peoples signed treaties with the U.S. government, surrendering their lands in return for various government commitments, including health care. The Indian Health Service (IHS) was born out of these agreements. The IHS is an agency in the U.S. Department of Health and Human Services under the U.S. Public Health Service. The IHS provides a comprehensive health service delivery system for approximately 2.7 million AI/AN who belong to 574 federally recognized Tribes/nations in 37 states. The aim of this paper is to make recommendations regarding the initiation of sustainable neurology care in marginalized or underserved populations by reviewing 40 years of neurology care provision within the IHS. We will discuss (1) the IHS, (2) neurological care provided within the IHS, including midlevel provider extension of neurology care and traditional medical care, and (3) select neurological diagnoses within AI/AN populations. Marginalized populations, including those in the United States that are rural, remote, or low socioeconomic status, lack access to specialty neurology care. This includes many AI/AN. The IHS has developed novel solutions to promote specialty care, including neurology. Notably, initial IHS investments in full-time neurology providers have led to more robust neurology care, often receiving attention from university programs. This suggests that an initial investment in stable on-site full-time neurology services provides a path to potential sustainable care for marginalized populations.

Paths and Mechanisms of Rural Transformation Promoted by Rural Collectively Owned Commercial Construction Land Marketization in China

Rural collectively owned commercial construction land marketization (RCCCLM), a land policy that is still being piloted despite being allowed by law, has been regarded as an indispensable policy tool that can meet the land demand for rural development. This study aims to analyze the typical modes and key paths of RCCCLM for rural transformation theoretically and practically. We developed an innovative theoretical framework of “Situation-Structure-Implementation-Outcome” to illustrate the relationship between RCCCLM and rural transformation. By tracing the process of the impact of RCCCLM on rural transformation in typical areas, this study fills the gap in existing research that has not yet explored the theoretical mechanisms between RCCCLM and rural transformation. The results show that a combination of such factors as geographical location and rural land use status brings about three major ways of RCCCLM, namely, local marketization, adjustive marketization and consolidation-based marketization, to promote rural transformation. The influencing mechanism of RCCCLM on rural transformation mainly concerns rights granting, rural land use structure reshaping, the transformation of farmers’ livelihood and improvement in rural governance capacity. Rural transformation follows a basic rule and phased characteristics of evolving from single function to multiple functions, and RCCCLM displays a differentiated driving effect on the evolution of rural functions in different stages of rural development. These findings will provide new insights into rural land use and rural transformation in China and other developing countries and help solve the bottlenecks in rural transformation.

Abstract 4822: Disparities in receiving non-surgical therapy impact outcomes in non-metastatic gastric cancer in Louisiana

Abstract Background: Given the history of evolving medical therapies and advancements in cancer treatments over the last decades, resectable gastric cancer has presented multiple strategies for care. Previous literature indicates historically decreased use of multimodal therapies in minority populations. This study aims to evaluate Louisiana patient populations for rates of definitive treatment, inequities in access to care, and evaluating its impact on the outcomes of minorities and underserved population. Methods: Patients with non-metastatic primary invasive gastric cancer, with T2-4 or any T status with positive lymph nodes, were identified in the Louisiana Tumor Registry using ICD-O codes and AJCC staging system. Receipt of non-surgical therapy was modeled using logistic regression. Overall survival (OS) was modeled using a Cox proportional hazards model. Results: The study included 561 patients, of which 37.6% (n=211) did not receive surgical treatment and 16.2% (n=91) did not receive non-surgical therapy. A subset of the cohort received no definitive treatment, (6.8%, n=38). In a demographic only multivariable model, adjusting for age, sex, and race, age 70 and over [OR (95%CI) =0.18 (0.08-0.42), p&amp;lt;0.001] and female sex [OR (95%CI) =0.48 (0.28-0.85), p=0.011] was associated with decreased rates of non-surgical therapy. Black [OR (95%CI) = 0.54 (0.31-0.93), p=0.027] and Hispanic [OR (95%CI) = 0.38 (0.13-1.08), p=0.070] race was associated with decreased receipt of non-surgical therapies. However, after adjusting for domestic partner, insurance status, rurality, area poverty, and surgery status, racial disparities were no longer significant compared to whites: Black [OR (95% CI) = 0.59 (0.33-1.06), p=0.075]; Hispanic [OR (95% CI) = 0.52 (0.17-1.66), p=0.272]. In multivariable analyses, receipt of surgery [HR (95% CI) = 0.3 (0.23 - 0.38), p&amp;lt;0.001) and any non-surgical therapy [HR (95% CI) = 0.43 (0.31 - 0.60), p&amp;lt;0.001) were associated with increased overall survival. Conclusion: A significant number of patients did not receive all modalities of the multidisciplinary treatment that is recommended for patients with non-metastatic gastric adenocarcinoma. Black patients and females are less likely to receive non-surgical modalities for gastric cancer in Louisiana, which is, at least, partially driven by socioeconomic determinants. Identifying patients with these risk factors is a crucial step in allocating resources to increase access the care and improve outcomes. Citation Format: Conner D. Hartupee, Kyla Maupin, Denise M. Danos, Omeed Moaven. Disparities in receiving non-surgical therapy impact outcomes in non-metastatic gastric cancer in Louisiana [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4822.

Abstract P387: Research Participation Rates and Characteristics in Underrepresented Groups in a West Virginia-Based Pregnancy Cohort Study

Introduction: Individuals living in rural areas, identifying as underrepresented racial minorities, and with low socioeconomic status tend to be poorly represented in research. Each underrepresented group experiences unique barriers that may prevent them from participating in research. Objectives and Hypothesis: This study aimed to test the hypotheses that 1) in a West Virginia-based pregnancy cohort study, individuals identifying as rural, an underrepresented racial minority, or receiving Medicaid/Medicare (as a surrogate for socioeconomic status) would have lower participation rates than typically better represented populations; and 2) that people from each underrepresented group would have different characteristics associated with screening for and consenting to participate in the pregnancy cohort study. Methods: Potentially eligible participants were sent recruitment messages via MyChart, a patient facing app linked to their electronic medical record. Upon receiving the message, participants could express their interest to participate in the study by filling out an eligibility screening form and, eventually, consent to participate at a study visit. Screening and consenting rates were calculated, stratified by rurality (i.e., urban, micropolitan rural, small town rural), race (i.e., white, underrepresented racial minority), and insurance status (i.e., Medicaid/Medicare, private). Logistic regression was used to test which characteristics were associated with screening for and participating in the study in each group. Results: Between October 2022 - April 2023, 1024 potential participants were sent recruitment messages. Screening rates (7.3% urban, 7.6% micropolitan rural, 8.8% small town rural; 7.3% White, 10.1% underrepresented racial minorities; 7.9% private insurance, 7.1% Medicaid/Medicare) and consenting rates (2.5% urban, 2.1% micropolitan rural, 4.6% small town rural; 2.8% White, 1.4% underrepresented racial minorities; 3.6% private insurance, 1.9% Medicaid/Medicare) were similar between different underrepresented groups and their better represented counterparts. For small town rural participants, preterm births (OR 6.85 [2.04 - 33.7]) and number of children (OR .24 [.05 - .71]) were associated with participating in the study. Those who identified as an underrepresented racial minority were more likely to screen for the study if they had private health insurance (OR 16.81 [1.53 - 500]). People with Medicaid/Medicare were more likely to participate in the study if they lived in a small town rural area (OR 7.71 [1.57 - 58.97]). Conclusion: Differences in characteristics associated with research participation suggest that researchers may need to tailor recruitment strategies to better consider characteristics of different underserved groups.

Evaluating the Association between the Implementation of the PoET (Prevention of Error-Based Transfers) Southwest Spread Project and Palliative Care Provision: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data

ObjectivesThe PoET (Prevention of Error-based Transfers) project seeks to align long-term care (LTC) home informed consent practices to existing legislation, thereby reducing consent-related error-based transfers to acute care. We sought to measure changes in resident-level palliative care provision after participating in the PoET Southwest Spread Project (PSSP), and to identify patient and LTC home characteristics associated with palliative care provision. DesignQuasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data. SettingSixty LTC homes (PSSP = 30; Control = 30) in Ontario, Canada, from November 2019 to December 2021. MethodsWe matched 30 PSSP to 30 control homes and described incidence rates for resident-level palliative care provision (ie, physician palliative care encounters and palliative medication prescriptions) during the 7-month postimplementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and palliative care provision during the postimplementation period. We adjusted for resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent subcohort to measure palliative care provision patterns during the last 2 months of life. ResultsWe captured a matched cohort of 8894 residents (PSSP = 4103; Control = 4791). Incidence rates of palliative care encounters increased during the postimplementation period for PSSP (82.6 to 85.4 per 100 person-months) but not for control residents (68.8 to 65.3 per 100 person-months). After adjusting for key covariates, PSSP exposure was associated increased palliative care provision (incidence rate ratio 2.47, 95% CI 2.31-2.64) and palliative care medication prescription (1.16, 95% CI 1.12-1.20). Larger home size, certain health regions, and higher number of comorbidities were associated with increased physician palliative care encounters. Conclusions and ImplicationsBy promoting correct informed consent practices in LTC, PSSP participation increased palliative care provision for PSSP LTC residents across all settings.

Rural-urban differences in meeting of physical activity recommendations by sun exposure and protection behaviors in the United States

ObjectiveTo examine associations between sun protection behaviors and physical activity (PA) by rural and urban residence in the United States. MethodsWe analyzed data from the National Health and Nutrition Examination Survey (2013–2018), restricting to participants ages 20–59 with sun behavior data. Sunburns, sun exposure, and sun protection measures were dichotomized (yes/no): ≥1 sunburn in the past year, 2+ hour outside during workdays or non-workdays, and never/rarely/sometimes using sunscreen, wearing long sleeves, and staying in the shade. Meeting PA recommendations (yes/no) was defined as ≥150 min of vigorous/moderate or ≥ 75 min vigorous PA per week. Associations between sun behaviors and PA were analyzed using logistic regression models, which accounted for survey-weights and potential confounders, and stratified by rural-urban status. ResultsRural and urban individuals meeting PA recommendations had greater odds of spending 2+ hour outside during workdays (OR: 2.26 [1.88, 2.74] and 3.95 [2.72, 5.73]) and non-workdays (OR: 2.06 [1.78, 2.38] and 3.33 [2.47, 4.46]). Among urban residents, odds of staying in the shade were lower among those who met PA recommendations (OR: 0.78 [0.66, 0.92]). We did not observe differences in sunburns or other sun behaviors by PA status, regardless of rurality. ConclusionsMeeting PA recommendations was associated with greater sun exposure in both rural and urban populations. Additional exercise location (indoors/outside) data is needed to inform PA and skin cancer prevention interventions to reduce unintended increases in sun exposure and reductions in PA, respectively, especially among rural populations.

Opioid stewardship program implementation in rural and critical access hospitals in Arizona.

The objective of this study is to examine rural hospitals' status in implementing opioid stewardship program (OSP) elements and assess differences in implementation in emergency department (ED) and acute inpatient departments. Health administrator survey to identify the number and type of OSP elements that each hospital has implemented. Arizona critical access hospitals (CAHs). ED and acute inpatient department heads at 17 Arizona CAHs (total of 34 assessments). Implementation of 11 OSP elements, by department (ED vs inpatient) and prevention orientation (primary vs tertiary). The percentage of implemented elements ranged from 35 to 94 percent in EDs and 24 to 88 percent in acute care departments. Reviewing the prescription drug monitoring program database and offering alternatives to opioids were the most frequently implemented. Assessing opioid use disorder (OUD) and prescribing naloxone were among the least. The number of implemented elements tended to be uniform across departments. We found that CAHs implemented, on average, 67 percent of elements that prevent unnecessary opioid use and 54 percent of elements that treat OUD. Some OSP elements were in place in nearly every Arizona CAH, while others were present in only a quarter or a third of hospitals. To improve, more attention is needed to define and standardize OSPs. Equal priority should be given to preventing unnecessary opioid initiation and treating opioid misuse or OUD, as well as quality control strategies that provide an opportunity for continuous improvement.

Survival outcomes for rural patients with advanced prostate cancer: A SEER investigation.

22 Background: It is unknown if the impact of rural versus urban settings may impact outcomes in men with metastatic prostate cancer, and in particular survival. This study aimed to examine differences in survival for patients in the United States with de novo metastatic prostate cancer, according to urban-rural status. Methods: This retrospective cohort study utilised data from the publicly available Surveillance, Epidemiology, and End Results database. Data on demographics, urban-rural status, histopathology, and survival were extracted for men aged 18-75 diagnosed with metastatic prostate cancer between 2009-2018. Rurality was re-classified from the rural-urban continuum code which ranged from 1 (most urban) to 9 (most rural). Individuals missing rurality status or survival-related data were excluded. Overall and cancer-specific survival between individuals living in urban and rural settings were analysed using multivariable Cox regression and adjusted restricted mean survival time modelling. Subgroup analyses were performed for histological subtypes of prostate cancer. Sensitivity analyses were performed using varying definitions of rurality. Results: Altogether, 21,291 individuals were included, with 2,510 living in rural settings, defined as rural-urban continuum code ≥ 4. The rural and urban participants differed in age, race, U.S. region, and marital status. There was no association between urban-rural status and overall survival (adjusted hazard ratio [HR] = 1.03, 95% confidence interval [CI]: 0.97-1.09, 11,333 events) or cancer-specific survival (1.03, 0.97-1.10, 9,380 events) using Cox regression models. Adjusted restricted mean survival time modelling demonstrated that urban patients lived 2.29 months longer than rural patients (95% CI: 0.61-3.97). Sub-analyses of neuroendocrine, intraductal, and other histological subtypes did not show an association between urban-rural status and overall survival. A more selective definition of rurality (rural-urban continuum code ≥ 5) resulted in a persisting difference in overall mean survival time (2.12 months, 0.24-4.01) using restricted mean survival time modelling. Similarly, a broader definition of rurality (rural-urban continuum code ≥ 3) also resulted in a difference in overall mean survival time (1.98 months, 0.59-3.36). Conclusions: This retrospective analysis demonstrated that a U.S. individual with metastatic prostate cancer who resided rurally died sooner compared to those from urban areas, suggesting greater disease impact in rural settings.