Oral Health Status of Children and Adolescents by Rural Residence, United States

CONTEXT: The limited information available on the oral health status of rural children in the United States makes it difficult to devise policy strategies to address perceived problems. PURPOSE: To document the oral health status and dental care utilization of US children by place of residence, METHODS: Data from National Health Interview Surveys for 1995, 1997, and 1998, and from the third National Health and Nutrition Examination Survey (1988-1994) were analyzed. FINDINGS: Children residing in rural areas were more likely to be uninsured for dental care than were children from urban areas (41.1% versus 34.7%). A greater percentage of rural than urban children reported unmet dental needs (7.5% versus 5.6%); there was no difference in self-reported poor dental status. Urban children were more likely than rural children to have visited the dentist in the past year (73.6% versus 69.9%) and were also more likely to be regular users of dental care (61.7% versus 51.4%). Differences in percentage of rural and urban children with caries lesions and caries experience were not significant. CONCLUSIONS: Children residing in rural areas have less access to and utilization of dental care compared to children residing in urban areas. Moreover, poor rural children display less utilization of dental services than poor urban children. Differences in the sum of decayed and filled primary teeth and the sum of decayed, missing, and filled permanent teeth were not significant.     

Is There a Role for the Small Rural Hospital?*

Rural hospitals represent almost half of all short-stay nonfederal general hospitals in the United States, but have been more severely affected than their urban counterparts by changes in reimbursement, regulation, and technology. Two hundred and six rural community hospitals closed during the first nine years of the 1980s, and the rate of closure is accelerating. Using secondary data sources to examine the structure, role, and content of rural hospitals, small rural hospitals are described and compared to larger and nonrural hospitals. Rural hospitals differ systematically from other hospitals in the United States, with smaller daily censuses, lower occupation rates, shorter lengths of stay, and disproportionately high shares of Medicare patients. They are dominated by very small institutions, with more than 1,000 rural hospitals having fewer than 50 beds. Small rural hospitals offer a core of basic services to the populations they serve. Emergency, obstetric, and newborn services are virtually ubiquitous in rural hospitals of all sizes, and they are also more likely to offer long-term nursing and home care services than urban hospitals of similar size. The inpatient diagnostic and procedural mix of these institutions demonstrates that they provide care for common medical and surgical conditions of low complexity. Rural hospitals are also relatively inexpensive, representing only 6 percent of total expenditures for hospital care. Given their central role in supporting the provision of health services to rural areas, the apparent appropriateness of the conditions they treat, and their relatively modest cost, it would seem reasonable to use federal policy to stabilize our previous investment in these institutions.     

Prevention of Unintended Pregnancy and HIV/STIs Among Latinos in Rural Communities: Perspectives of Health Care Providers

Latino women in the United States are disproportionately at risk for unintended pregnancy, HIV, and sexually transmitted infections (STIs). We conducted nine focus groups with health care practitioners who provide reproductive health care to Latinos in rural areas of the Northwest. From the practitioner perspective, we explored barriers and facilitators to the acquisition and use of contraceptives and to the prevention of HIV/STIs among rural Latinos. Suggestions for improving reproductive health care included Spanish-language resources/materials and convenient contraceptive methods. Findings provide context to the complex issues related to unintended pregnancy and disease prevention among Latinos residing in rural communities.     

A “Medical Mission” at Home: The Needs of Rural America in Terms of Otolaryngology Care

Objectives: Describe the population, Medicaid, uninsured, and otolaryngology practice demographics for 7 representative rural Southeastern states, and propose academic‐affiliated outreach clinics as a service to help meet the specialty care needs of an underserved rural population, based on the “medical mission” model employed in international outreach clinics. Methods: A needs assessment was conducted via review of medical licensing and practice location data from state medical licensing authorities, together with population, Medicaid, and uninsured data from state health/human services departments and the US Census Bureau. Results: In all states examined, there are significantly more practicing otolaryngologists per capita in urban areas compared to rural areas (P < .05), with the exception of West Virginia, where the difference was not statistically significant (P= .33). In the majority of the states examined, there were higher rates (expressed as a percentage of total county population) of both Medicaid recipients and uninsured patients in rural counties compared to urban counties. Notable exceptions include Louisiana and West Virginia, where there are higher percentages of Medicaid patients in urban areas, and Kentucky and Tennessee, where there are higher percentages of uninsured patients in the urban areas (P < .05 for each comparison). Conclusions: Borrowing design elements from the international outreach clinics, which involve many US otolaryngologists, a similar medical mission model could be of benefit domestically. There are rural areas of the Southeast where visiting outreach clinics could improve access to otolaryngology care and facilitate effective use of existing “safety net” health care resources.     

Health Care Needs of the Growing Latino Population in Rural America: Focus Group Findings in One Midwestern State

Latinos represent nearly 13% of the U.S. population, surpassing African-Americans as the nation's largest racial/ethnic group. Many rural midwestern communities are seeing unprecedented growth in their Latino populations, creating new challenges and pressures for health and social service providers. This study is based on four focus groups conducted in three rural communities to examine concerns with health care services and access to care. Focus group analysis found several key barriers to health care access, including cost of health care services and frustration with the complexity of the U.S. health care system, as well as language and cultural issues that adversely affect patient-provider relationships. In addition, a number of impediments related to employer-sponsored health coverage were identified, including prohibitive premium costs as well as concerns about occupational injuries and access to care during work hours. The growth of the Latino population in the rural Midwest will require changes in existing health and social service systems to serve as a bridge to new systems in this country. We recommend several policy options including premium subsidies for low-wage jobs, community-based enrollment specialists for public programs, and continued research and data collection to monitor change and progress.     

Quality of health care for ethnic/racial minority populations

This article reviews the composition and characteristics of the health professions, the demographics of the national population, and factors that influence access to health care and satisfaction with care for ethnic/racial minority populations in the United States. In addition, an overview of publicly funded US health insurance programs for the poor is provided along with a discussion of the impact that managed care is having on the American health care system. Finally, the paper summarizes conference discussions regarding the problems, strategies, and approaches that the UK and the US have experienced with respect to providing quality health care for ethnic/racial minority populations.     

Primary care: choices and opportunities for racial/ethnic minority populations in the USA and UK--a comparative analysis

This paper examines and compares the choices made and the opportunities provided by the United States and the United Kingdom in delivering primary care services to their racial/ethnic minority populations. While both nations agree that the most effective strategy for health service delivery to a diverse population lies in primary care, their approaches to obtaining this goal have been quite different. Sociological theories of functionalism and conflict perspective provide the analytical and organizing framework of the paper. Within this theoretical context, the health systems in place in each country are examined as an outgrowth of the larger socio-political, economic and cultural structures of the US and UK. Analysis of the advance of managed care in the US and the recent NHS reforms are also discussed in terms of lessons learned and the difficulties that lay ahead in order to ensure that these new developments contribute significantly to eliminating the disproportionately worse health status of racial ethnic minorities. Towards that goal the paper identifies opportunities for collaboration and specific recommendations for future action by both countries.     

Update: Health Insurance and Utilization of Care Among Rural Adolescents

CONTEXT: Adolescence is critical for the development of adult health habits. Disparities between rural and urban adolescents and between minority and white youth can have life-long consequences. PURPOSE: To compare health insurance coverage and ambulatory care contacts between rural minority adolescents and white and urban adolescents. METHODS: Cross-sectional design using data from the 1999-2000 National Health Interview Survey, a nationally representative sample of US households. Analysis was restricted to white, black, and Hispanic children aged 12 through 17 (8,503 observations). Outcome measures included health insurance, ambulatory visit within past year, usual source of care (USOC), and well visit within past year. Independent variables included race, residence, demographics, facilitating/enabling characteristics, and need. RESULTS: Across races, rural adolescents were as likely to have insurance (86.8% vs 87.7%) but less likely to report a preventive visit (60.1% vs 65.5%) than urban children; residence did not affect the likelihood of a visit or a USOC. Minority rural adolescents were less likely than whites to be insured, report a visit, or have a USOC. Most race-based differences were not significant in multivariate analysis holding constant living situation, caretaker education, income, and insurance. Low caretaker English fluency, limited almost exclusively to Hispanics, was an impediment to all outcomes. CONCLUSIONS: Most barriers to care among rural and minority youth are attributable to factors originating outside the health care system, such as language, living situation, caretaker education, and income. A combination of outreach activities and programs to enhance rural schools and economic opportunities will be needed to improve coverage and utilization among adolescents.     

How does a changing country change family practice?

The US population is changing. Ethnic minorities are now the fastest growing segment of the US population, and they have higher mortality rates than the remainder of Americans. Members of minority groups also earn less and are twice as likely as other residents to lack medical insurance. Minority communities have poorer health and access to care than the remainder of the population. Women constitute more than half the total population of the United States and are half of the labor force. Family structure has changed such that 53% of African-American, 32% of Hispanic, and 27% of all families were headed by a single parent in 1992. The elderly population has also increased and has a greater prevalence of chronic disease. The physician workforce has more female and younger physicians than in the past but a still-inadequate number of minority physicians. In contrast to the low proportion of minorities in the US physician workforce, women now comprise approximately half of medical students. A major economic trend affecting health care access in the United States is the lack of secure insurance coverage for 44 million people in 1998. Rates of no insurance are higher among minorities, households with no full-time worker, the near poor, and among persons with less education. Private charitable services, as well as the formal safety net systems, are experiencing financial pressure in the United States, further jeopardizing access to care for the uninsured. The average family in the United States is now working harder--but earning less money. The changing population mix, shifting gender balance, increasing proportion of elderly, and major socioeconomic trends and income disparities occurring in the United States today have shaped a practice environment that differs from whatfacedfamily physicians 30 years ago. Thus, a change in approach to training and practice is needed, while preserving the critical relationship we have with our patients and continuing to meet their needs.     

Cardiovascular disease among women residing in rural America: epidemiology, explanations, and challenges

Many believe that the United States has entered a "Golden Age" of cardiovascular health and medicine. Pharmacological and technological advances have indeed produced an era of declining mortality rates from cardiovascular diseases for the nation as a whole. However, there remain areas of challenge. Cardiovascular disease (CVD) is still by far the leading cause of death and disability in the United States, and it is the leading killer of US women. Perhaps the single most notable feature of the CVD epidemic in the United States is the substantial difference in morbidity and mortality that exists between White women and women of color, with a disproportionate share of suffering borne by minority women. Unexplained regional variations also cloud the otherwise notable progress of the last 30 years, and many rural areas appear to be uniquely affected by cardiovascular disease. This commentary reviews the evidence that the CVD epidemic disproportionately burdens women of color who reside in rural areas, itemizes and provides a logical framework for explaining this burden, and suggests approaches to solving this vexing public health problem.     

Prevalence of Rural Intimate Partner Violence in 16 US States, 2005

ABSTRACT:  Context: Intimate partner violence (IPV) is a public health problem that affects people across the entire social spectrum. However, no previous population-based public health studies have examined the prevalence of IPV in rural areas of the United States. Research on IPV in rural areas is especially important given that there are relatively fewer resources available in rural areas for the prevention of IPV. Methods: In 2005, over 25,000 rural residents in 16 states completed the first-ever IPV module within the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a Centers for Disease Control and Prevention-sponsored annual random-digit-dialed telephone survey. The BRFSS provides surveillance of health behaviors and health risks among the non-institutionalized adult population of the United States and several US territories. Findings: Overall, 26.7% of rural women and 15.5% of rural men reported some form of lifetime IPV victimization, similar to the prevalence found among men and women in non-rural areas. Within several states, those living in rural areas evidenced significantly higher lifetime IPV prevalence than those in non-rural areas. Conclusion: IPV is a significant public health problem in rural areas, affecting a similar portion of the population as in non-rural areas. More research is needed to examine how the experience of IPV is different for rural and non-rural residents.     

Diagnosed Mental and Physical Health Conditions in the united States Nursing Home Population: Differences Between Urban and Rural Facilities

CONTEXT: There has been limited examination of the differences in health characteristics of the rural long-term care population. Recognizing these differences will allow policymakers to improve access to long-term care services in rural communities. PURPOSE: To determine whether differences in likelihood of diagnosis exist between urban and rural nursing home residents for 8 common medical conditions: 4 mental health conditions (depression, anxiety, Alzheimer's, and non-Alzheimer's dementia) and 4 physical health conditions (cancer, emphysema/chronic obstructive pulmonary disease, heart disease, and stroke/transient ischemic attack). METHODS: We used multivariate logistic regression to examine data derived from the 1996 Nursing Home Component of the Medical Expenditure Panel Survey, a multistage stratified probability sample of 815 nursing homes and 5899 residents, representing 3.1 million individuals in the United States who spent 1 or more nights in nursing homes during 1996. FINDINGS: Residents in rural homes were less likely to be diagnosed with depression compared to those in homes in large metropolitan areas, and residents in homes in small metropolitan areas were less likely to have cancer than those in large metropolitan areas. Diagnostic status between urban and rural residents was comparable for the other 6 conditions. CONCLUSIONS: Further research is necessary to determine whether and why depression is inadequately diagnosed in rural nursing homes and to ascertain which types of cancer are responsible for the observed differential. Such research is particularly important for elderly nursing home residents who are more likely to suffer from chronic conditions that require significant medical supervision.     

2000-2018年我国城乡居民医疗保健支出公平性变化研究

目的:了解我国城乡及地区间医疗保健支出现状及差异性,分析我国城乡居民医疗保健支出的公平性,为我国医药卫生体制改革提供科学参考。方法:收集2000—2018年城乡医疗保健支出、人均可支配收入及人均纯收入等相关数据,采用集中指数和集中曲线对我国城乡医疗保健支出进行公平性分析。结果:2010—2018年城镇居民人均医疗保健支出(实际值)年平均增长速度为3.55%,农村居民人均医疗保健支出(实际值)年平均增长速度为10.00%。2000—2017年我国城镇居民人均医疗保健支出集中指数呈下降趋势,其中2006年出现最大值为0.1332,除2015—2017年外,其余年份差异均具有统计学意义(P<0.05);2000—2017年我国农村居民人均医疗保健支出集中指数呈下降趋势,2004年出现最大值为0.2522,差异均具有统计学意义(P<0.05)。结论:我国城乡人均医疗保健支出逐年增加,全国和各地区城乡人均医疗保健支出差距较大。我国城乡人均医疗保健支出存在不公平性,城镇人均医疗保健支出优于农村人均医疗保健支出,公平性逐渐趋好。     

Associations of Rural Residence With Timing of HIV Diagnosis and Stage of Disease at Diagnosis,South Carolina 2001-2005

Context: Rural areas in the southern United States face many challenges, including limited access to health care services and stigma, which may lead to later HIV diagnosis among rural residents. Purpose: To investigate the associations of rural residence with timing of HIV diagnosis and stage of disease at diagnosis. Methods: Timing of HIV diagnosis was categorized as a diagnosis of acquired immune deficiency syndrome within 1 year of a first positive HIV test or HIV-only. Stage of disease was based on initial CD4+ T-cell count taken within 1 year of diagnosis. County of residence at HIV diagnosis was classified as urban if the population of the largest city was at least 25,000; it was classified as rural otherwise. Logistic regression was used to analyze timing of HIV diagnosis, and analysis of covariance was used to analyze stage of disease. Findings: From 2001 to 2005, 4,137 individuals were diagnosed with HIV infection. Of these, 1,129 (27%) were rural and 3,008 (73%) were urban residents. Among rural residents, 533 (47%) were diagnosed late, compared with 1,258 (42%) urban residents. Rural residents were significantly more likely to be diagnosed late (OR 1.19 [95% CI, 1.02-1.38]). Rural residence was associated with lower initial CD4+ T-cell count in crude analysis (P= .01) but not after adjustment (P > .05). Conclusions: Rural residence is a risk factor for late HIV diagnosis. This may lead to reduced treatment response to antiretroviral medications, increased morbidity and mortality, and greater HIV transmission risks among rural residents. New testing strategies are needed that address challenges to HIV testing and diagnosis specific to rural areas.     

Where to Seek Care: An Examination of People in Rural Areas With HIV/ AIDS

Though HIV/AIDS has spread to rural areas, little empirical evidence is available on where patients living in these areas receive care. This article presents estimates of rural residents in care for HIV/AIDS, their demographic and health-related characteristics, information about whether they receive care in a rural or urban setting, and data on the drug therapies prescribed. The estimates come from the HIV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV-infected adults receiving care in the contiguous United States. Regardless of the definition used--enrollment site, usual source of HIV care, or site of most recent hospitalization--almost three quarters of rural residents with HIV/AIDS obtained their health care in urban areas. The authors find that differences in the demographic characteristics of those using urban vs. rural care do not drive the decision on where to obtain care, with the primary difference being that people with a rural provider tend to be older. Rural residents with an urban usual source of HIV care incurred significant inconvenience in obtaining care--the majority said their care was not conveniently located, they had substantially longer mean travel times, and over 25% had put off obtaining care in the past 6 months because they did not have a way to get to their provider. Given the considerable burden this places on a chronically ill population,further research is needed to explore how provider supply and provider experience affect the decision to travel for care and how quality of care is affected.     

Selected Comparisons and Implications of a National Rural and Urban Survey on Health Care Access, Demographics, and Policy Issues

As the national health debate evolved over the past two years, a need to better understand the differential constraints of rural health delivery and popular attitudes toward policy initiatives became apparent. Selected 1994 and 1995 results of two national surveys designed to compare rural and urban household responses are reported. The average distance those living in rural households must travel to access medical providers and emergency care is nearly double that of urban household residents. Rural household resident responses show a higher level of acceptance of nonphysician health care providers such as physicians assistants and registered nurses. Means testing of Medicare programs and use of special indicators for providing more Medicaid funds to states with medically underserved and sparsely populated areas are examples of two policy initiatives that receive favorable responses from both urban and rural household residents, but would disproportionately benefit rural areas.     

Factors in Recruiting and Retaining Health Professionals for Rural Practice

CONTEXT: Rural communities, often with complex health care issues, have difficulty creating and sustaining an adequate health professional workforce. PURPOSE: To identify factors associated with rural recruitment and retention of graduates from a variety of health professional programs in the southwestern United States. METHODS: A survey collecting longitudinal data was mailed to graduates from 12 health professional programs in New Mexico. First rural and any rural employment since graduation were outcomes for univariate analyses. Multivariate analysis that controlled for extraneous variables explored factors important to those who took a first rural position, stayed rural, or changed practice locations. FINDINGS: Of 1,396 surveys delivered, response rate was 59%. Size of childhood town, rural practicum completion, discipline, and age at graduation were associated with rural practice choice (P < .05). Those who first practiced in rural versus urban areas were more likely to view the following factors as important to their practice decision: community need, financial aid, community size, return to hometown, and rural training program participation (P < .05). Those remaining rural versus moving away were more likely to consider community size and return to hometown as important (P < .05). Having enough work available, income potential, professional opportunity, and serving community health needs were important to all groups. CONCLUSION: Rural background and preference for smaller sized communities are associated with both recruitment and retention. Loan forgiveness and rural training programs appear to support recruitment. Retention efforts must focus on financial incentives, professional opportunity, and desirability of rural locations.     

Impact of Community Health Workers on Access to Care for Rural Populations in the United States: A Systematic Review

Community Health Worker (CHW) interventions have shown potential to reduce inequities for underserved populations. However, there is a lack of support for CHW integration in the delivery of health care. This may be of particular importance in rural areas in the Unites States where access to care remains problematic. This review aims to describe CHW interventions and their outcomes in rural populations in the US. Peer reviewed literature was searched in PubMed and PsycINFO for articles published in English from 2015 to February 2021. Title and abstract screening was performed followed by full text screening. Quality of the included studies was assessed using the Downs and Black score. A total of 26 studies met inclusion criteria. The largest proportion were pre-post program evaluation or cohort studies (46.2%). Many described CHW training (69%). Almost a third (30%) indicated the CHW was integrated within the health care team. Interventions aimed to provide health education (46%), links to community resources (27%), or both (27%). Chronic conditions were the concern for most interventions (38.5%) followed by women’s health (34.6%). Nearly all studies reported positive improvement in measured outcomes. In addition, studies examining cost reported positive return on investment. This review offers a broad overview of CHW interventions in rural settings in the United States. It provides evidence that CHW can improve access to care in rural settings and may represent a cost-effective investment for the healthcare system.

     

Medication Safety Issue Brief. Small and rural hospitals--unique challenges, unique solutions

Small rural hospital pharmacies face ths same quality challenges as their large, urban counterparts. Yes, they often lack access to the necessary resources to address these issues. That's no minor problem. AHA Hospital Statistics 2006 reports that 2,003 (41 percent) of the nation's 4,919 community hospitals in 2004 were rural. And, as of Aug. 31, 2005, 1,141 hospitals in the United States are designated as critical access hospitals. People living in rural areas are less likely to have insurance and are by and large poorer than those who live in urban areas, according to the National Rural Health Association. The rural population is also older and tends to suffer from more chronic diseases than residents of urban areas. That adds to the challenge for small and rural hospitals. These facilities must treat complex medical cases with limited resources, often with minimal on-site pharmacy coverage.