School of Public Health

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Diabetes Mortality in Rural America: 1999-2015
(2017-08) Callaghan, Timothy H.; Towne Jr, Samuel D.; Bolin, Jane; Ferdinand, Alva O.
One of the most important tasks for rural scholars and policymakers is to better understand the causes and consequences of diabetes, as diabetes prevalence is generally higher in rural areas than urban areas. This study explores diabetes-related mortality, comparing urban-versus-rural mortality over a sixteen-year period, and investigating the influence of race and rurality. The study uses data from the Centers for Disease Control and Prevention Wonder Database. Results demonstrated that as rurality increases in America, so too does diabetes-related mortality. Mortality attributable to diabetes is dramatically higher for Black Americans than Whites in both rural and urban areas, although rural-urban disparities follow similar trends for both groups. Hispanics, despite having lower diabetes-related mortality than Whites, also demonstrated higher rural rates of mortality than urban. Resources should be devoted to better understanding the causes and consequences of these findings, and to developing effective interventions aimed at eliminating disparities in diabetes mortality based on rurality and race.
Diabetes and Forgone Medical Care due to Cost in the U.S. (2011-2015): Individual-level and Placed-based Disparities
(2017-08) Towne Jr, Samuel D.; Bolin, Jane; Ferdinand, Alva O.; Nicklett, Emily Joy; Smith, Matthew Lee; Callaghan, Timothy H.; Ory, Marcia G.
Diabetes, particularly Type 2 diabetes, affects millions of Americans with a particular burden placed on more vulnerable populations. Underlying factors (e.g., residing in low-resource rural areas) may contribute to poor health-related outcomes for persons with diabetes. This study used 2011-2015 data from the Behavioral Risk Factor Surveillance System (BRFSS), to investigate trends in diabetes rates and forgone medical care among persons with diabetes in the U.S. and to identify geographic determinants (i.e., place-based) and other social determinants of health disparities. Results indicate that both the southern U.S. and rural areas faced a greater burden of diagnosed diabetes. Areas that failed to expand Medicaid through the Affordable Care Act may face a greater burden of both diabetes and forgone medical care due to cost among those with diagnosed diabetes. This study highlighted the critical role that both individual-level and place-based (i.e., geospatial factors), namely region and rurality, play in diabetes and forgone medical care. Practical applications of this study include a call for increased focus on prevention, diagnosis, and diabetes self-care education and proper maintenance of diabetes among at-risk populations.
Diabetes-Related Hospital Mortality in Rural America: A Significant Cause for Concern
(2018-03) Ferdinand, Alva O.; Akinlotan, Marvellous; Callaghan, Timothy H.; Towne Jr, Samuel D.; Bolin, Jane
It has been reported that diabetes prevalence is higher in rural areas than in urban areas. Other studies have shown that rural persons with diabetes have higher morbidity from diabetes-related complications than urban persons with diabetes. This study used data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (2009-2014) to examine hospital-based diabetes-related mortality and whether there were urban-rural differences across census regions. On average 2.63% of all diabetes-related urban hospital admissions resulted in death, while 2.73% of all diabetes-related rural hospital admissions resulted in death (p<0.001). Mortality rates were highest within rural areas of the South and Midwest (21.0 and 15.1 deaths per 100,000 population, respectively) compared to other areas in both regions. The noncore, micropolitan, and small metropolitan areas of the South had the highest average diabetes-related hospital mortality rates (21.0, 20.3, and 14.0 deaths per 100,000 population, respectively) compared to corresponding areas in the Northeast, Midwest, and West regions. Results suggest that substantial differences exist between rural and urban diabetes-related hospital mortality. Furthermore, the burden is especially pronounced for rural residents in the South and Midwest census regions.
Cancer Mortality in Rural America
(2018-11) Callaghan, Timothy H.; Ferdinand, Alva O.; Towne Jr, Samuel D.; Akinlotan, Marvellous; Primm, Kristin; Bolin, Jane
For scholars and policymakers alike, understanding the burden of cancer on society is a critical topic for investigation. Cancer consistently ranks as the second leading cause of death in the U.S., and cancers of the prostate, breast, lung, and colorectal areas are particularly problematic. This policy brief works to understand the scope of cancer mortality in urban and rural areas of the U.S. and across census regions. It finds that age-adjusted mortality rates are higher for lung, prostate, and colon cancer in rural areas than in urban areas but also that mortality rates are lower for breast and cervical cancers in rural areas than in urban areas. In addition, this brief identifies important discrepancies in cancer mortality across regions, with lower rates in the West for all analyzed cancer types except prostate cancer, and higher rates for most cancers in the rural South.
The Development of Telehealth Laws in the U.S. from 2008 to 2015: A Legal landscape
(2019-11) Schmit, Carson D.; Ferdinand, Alva O.; Callaghan, Timothy H.; Kageyama, Mariko; Khodakarami, Nima; Morrisey, Michael A.
Rapid technological advances make telehealth a moving target for regulators. This study examines the scope and evolving nature of telehealth statutes (i.e., laws passed by state legislatures) and regulations (i.e., laws promulgated by state executive agencies) in the U.S. Our research aims to understand changes in telehealth laws over time (2008-2015), variations in legal frameworks established across the U.S., and the extent that state laws regulate the primary care delivery through the use of telehealth. We found that the number of states with broadly worded laws that authorize a variety of healthcare professional to provide care via telehealth more than tripled between 2008 and 2015 (from 3 to 10). A legal analysis suggests that enabling regulations on telehealth payment for Medicaid are relatively rare in the eastern U.S. and that laws governing private insurance telehealth payments are more geographically defused. Examining differences in the adoption of telehealth laws by state proportions on rurality and urbanicity indicates that states with large urban populations also see the utility of a regulatory environment supports telehealth as an avenue for increased access to care for rural residents.
Prevalence and Mortality of Heart Disease and Related Conditions: Disparities affecting the South, Rural Areas, and American India, and Alaska Natives
(2019-11) Towne Jr, Samuel D.; Callaghan, Timothy H.; Ferdinand, Alva O.; Akinlotan, Marvellous; Primm, Kristin; Bolin, Jane
Across the U.S., major health inequities persist across several social and structural determinants of health. In this brief, we explored the intersection of these social and structural determinants across major diseases and disease-related mortality. The likelihood of stroke, angina or coronary heart disease, and heart attack (myocardial infarction) was significantly higher in the South and for American Indian or Alaska Native individuals as compared to White individuals. Rural areas of the South experienced high rates of mortality for multiple years related to congestive heart failure, ischemic heart disease, and stroke and cerebrovascular disease. Stroke and cerebrovascular disease mortality were highest in the South as compared to all other regions. Major declines were identified in mortality rates for ischemic heart disease over time (2006-2016). Both region and rurality were critical in assessing mortality with major variation in rates of mortality across each. Major inequities identified in this brief can serve as targets for policymakers in terms of providing additional resources to help reduce the burden of disease facing at-risk populations, particularly rural residents, residents of the South, and American Indians and Alaska Natives.
Community Health Worker Roles and Responsibilities in Rural and Urban America
(2019-11) Callaghan, Timothy H.; Washburn, David J.; Schmit, Carson D.; Martinez, Denise; Thompson, Emily; Lafleur, Megan; Ruiz, Zuleyma
This project investigated the Community Health Worker (CHW) field in rural and urban environments using a series of focus groups of CHWs in four states. Our findings suggest that there is not a "typical" CHW. Despite this, our results show that CHWs in rural and urban areas share two commonalities—their role as bridge figures between communities and needed resources and their unique position in helping the healthcare industry address social determinants of health. An important difference we observed is that rural CHWs took on a more "generalist" role due to lack of resources, programs, and services, whereas urban CHWs took on a more "specialist" role because of the sometimes substantial amount of available resources, programs, and services.
Are Rural Infants Benefiting from WIC Food Package Rule Changes? Breastfeeding and Infant Feeding Behaviors
(2020-02) Ishdorj, Ariun; Di, Hongyang; Samman, Elfreda; McKyer, E. Lisako J.
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides healthy foods and services to low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, as well as to infants and children up to age 5. In 2009, revisions were made to the WIC program to further improve the nutrition and health of infants by providing benefits to promote and support breastfeeding among those who are able and to improve infant feeding practices. This study compared breastfeeding initiation for rural and urban WIC participants, as well as changes in breastfeeding and infant feeding practices before and after the WIC Food Packages (WIC-FPs) revisions. Secondary data from the National Food and Nutrition Survey were used consisting of data from 58 WIC programs representing 38 states, two U.S. districts and territories, and 10 Indian/tribal organizations. Our results revealed breastfeeding for WIC participants continues to move in a positive direction with evidence showing a significant increase in fully breastfeeding post WIC-FP revisions in both rural and urban participants. Our findings for infant feeding revealed an improvement in feeding practices post WIC-FP revisions, such as a delay in the introduction of solid food. Rural participants, however, were still lagging behind their urban counterparts.
Healthy People 2020 Progress for Leading Causes of Death in Rural and Urban America: A Chartbook
(2020-03) Callaghan, Timothy H.; Ferdinand, Alva O.; Akinlotan, Marvellous; Primm, Kristin; Lee, Ju Sung; Macareno, Blanca; Bolin, Jane
Rural Americans have historically faced significant challenges in accessing healthcare and preventive healthcare services, including ambulatory care, dental care, emergency services, and pharmaceutical services. Rural Americans are more likely to die from conditions generally considered self-manageable or preventable. This study examines rural versus urban differences in how the U.S. is meeting the Healthy People 2020 mortality objectives for many of the leading causes of death. Our analyses use national vital statistics mortality data available through the Centers for Disease Control and Prevention's Wonder website. Overall, our findings indicate rural America is lagging behind urban America in achieving these objectives. Furthermore, key findings indicate men have been less likely than women to achieve these objectives, the rural South has seen less progress than other regions toward many of the objectives, and suicide mortality has increased across all levels of rurality.
Post-Acute Skilled Nursing Care Availability in Rural United States
(2020-07) McMaughan, Darcy; Anikpo, Ifedioranma O.; Horel, Scott; Ozmetin, Jennifer
This study explores factors related to post-acute skilled nursing care utilization in rural areas of the U.S. The analyses uses county-level Area Health Resource Files, National Center for Health Statistics Urban-Rural codes, and data from the Flex Monitoring Team database. We found counties lacking post-acute skilled nursing care were more likely to be noncore, sparsely populated, and less impoverished counties. The elderly population percentage, number of hospitals with high utilization rates, and Hispanic population percentage were not significantly associated with the availability of post-acute skilled nursing care. This research shows that portions of rural America are possibly skilled nursing deserts, thus lacking the physical presence of facilities to provide post-acute skilled nursing care. This potentially affects more than 740,000 rural residents, among them about 127,000 elderly individuals, residing in 153 rural counties.
Rural Versus Urban Prevalence of Intimate Partner Violence-Related Emergency Department Visits, 2009-2014
(2020-08) Perez-Patron, Maria J.; Downing, Nancy R.; Montalvo-Liendo, Nora; Taylor, Brandie D.
This retrospective study examines the prevalence of IPV-related emergency department (ED) visits by rural and urban status and U.S. census regions using discharge data from the National Emergency Department Sample. Key findings indicate IPV-related ED visits among patients ages 15-64 were higher in rural versus urban areas in all regions except the Midwest. Women ages 15-64 represented 93% of IPV-related ED visits in urban areas compared to 95% in rural areas. Both rural men and women admitted to the ED with an IPV-related diagnosis were more likely to be in the lower half of the income distribution and to have public health insurance than their urban counterparts.
Trends in Singleton Preterm Birth by Rural Status in the U.S., 2012-2018
(2021-04) Perez-Patron, Maria J.; Page, Robin L.; Olowolaju, Samson; Taylor, Brandie D.
This study examines singleton preterm birth rates from 2012-2018 by rurality and census region using birth certificate data from the National Center for Health Statistics. The data showed preterm singleton birth rates were consistently higher in rural versus urban areas across all race and ethnic groups, payment sources for delivery, and persons participating in the Women, Infants, and Children program. The increased risk for infant and maternal mortality and morbidity in rural areas highlights the importance of health assistance programs for pregnant women, mothers, and children in these rural communities.
Influenza and Pertussis Vaccination Rates Among Pregnant Women in Rural and Urban Area
(2021-04) Regan, Annette; Kaur, Ravneet; Callaghan, Timothy H.
This study evaluates the receipt of influenza and pertussis vaccines among pregnant women from 2012-2018 in the U.S. using data from the Pregnancy Risk Assessment Monitoring System. The data showed the percentage of influenza vaccination among rural pregnant women was lower than their urban counterparts with significant differences in certain subgroups. The data, however, for pertussis vaccination in pregnant women across the urban-rural continuum showed similar percentages overall but with some differences observed in subgroups. This study suggests important gains have been made in maternal vaccination, but significant differences persist across the urban-rural continuum.
The Co-occurrence of HIV and Opioid Mortality in Rural and Urban America from 1999-2018
(2021-06) Callaghan, Timothy H.; Primm, Kristin; Akinlotan, Marvellous; Khodakarami, Nima; Vadali, Meera; Bolin, Jane; Ferdinand, Alva O.
Previous research has noted that the U.S. is facing dual public health crises associated with opioid use disorder (OUD) and human immunodeficiency virus (HIV). Fatalities associated with OUD have been reported with increasing frequency, and researchers have posited that the injection of opioids could have implications for HIV rates and mortality. The current body of literature outlining connections between HIV and OUD does not account for differences in rural and urban areas. Using the Centers for Disease Control and Prevention Wide-ranging Online Date for Epidemiology Research mortality database, this brief finds no positive relationship between opioid mortality and HIV mortality over time. Instead, the results show a consistent decline in HIV mortality rates and a troubling rise in deaths from opioids across the time period analyzed.
Rural-Urban Variation in Travel Burden for Care: Findings from the 2017 National Household Travel Survey
(2021-07) Akinlotan, Marvellous; Primm, Kristin; Khodakarami, Nima; Bolin, Jane; Ferdinand, Alva O.
Using National Household Travel Survey (NHTS) data, this project examines differences in travel patterns to medical and dental care in the U.S. based on the rurality classification, socio-demographic, and geographic characteristics of the survey population. Findings indicate that the average distance traveled for medical and dental care has changed little since the last analysis of NHTS data in 2001. The findings did note that among rural residents, Blacks and Hispanics, older residents, those with low incomes, those who seek care during night hours, and those who live in the Midwest census region bear a disproportionate burden of travel for care.
Rural Urban Variation in Travel Burden for Care: Findings from the 2017 National Household Travel Survey
(2021-12) Akinlotan, Marvellous; Primm, Kristin; Khodakarami, Nima; Bolin, Jane; Ferdinand, Alva O.
Using National Household Travel Survey (NHTS) data, this project examines differences in travel patterns to medical and dental care in the U.S. based on the rurality classification, socio-demographic, and geographic characteristics of the survey population. Findings indicate that the average distance traveled for medical and dental care has changed little since the last analysis of NHTS data in 2001. The findings did note that among rural residents, Blacks and Hispanics, older residents, those with low incomes, those who seek care during night hours, and those who live in the Midwest census region bear a disproportionate burden of travel for care.
An Examination of the Workforce in Rural America
(Texas A&M University, 2023) Brandford, Arica; Falia, Gogoal; Fahrenwald, Nancy; Clark, Heather; Bolin, Jane; Rigsby, Matilin; Kolade, Fiyinfolu
It is important to leverage the healthcare workforce in new and innovative ways, with more care taking place outside of traditional settings. Flexibility in the way individuals connect with and engage in care is critical. Relationships are central to the development, forward progress, and collective action of community-based partnerships and collaborations. Often, evaluation of partnerships or community collaborative efforts focuses on achieving outcomes and effectiveness; however, community capacity building has many dimensions including: skills and resources, nature of social relations, structures and mechanisms for community dialogue, civic participation, value systems, and learning culture. Continued expansion of telehealth as a means of healthcare provision means identifying evidence-based practices and policy changes to address challenges. There is a need to improve the quality and standardization of data to fully demonstrate and understand the impact of telehealth and identify where disparities persist. Telehealth plays a key role in helping to address workforce issues by enhancing access and reducing burnout.
Rural Healthcare Access and Quality
(Texas A&M University, 2023) Callaghan, Timothy H.; Trujillo, Kristen Lunz; Lockman, Alee; Falia, Gogoal
In the past decade, healthcare access and quality in the U.S. have improved significantly, largely due to the Affordable Care Act (ACA), which enabled millions to obtain affordable health insurance. This has facilitated increased access to healthcare services and reduced the burden of uncompensated care. Technological advancements have further enhanced access through telehealth, allowing more Americans to receive timely care. However, disparities in healthcare access and quality persist, particularly in rural areas. Rural Americans often lack health insurance, face travel barriers to care, experience health professional shortages, and are affected by hospital closures. Additionally, inadequate internet and device access limits telehealth’s potential. Similar challenges affect minority groups and those in states without Medicaid expansion. To bridge these gaps, policy changes are essential. Expanding Medicaid, improving internet coverage for telehealth, addressing health professional shortages, supporting rural hospitals, and reducing prescription drug costs are critical steps. Policies like the Inflation Reduction Act are underway, and their impact on rural health must be monitored over the coming decade.
Rural Substance Misuse Trends in America
(Texas A&M University, 2023) Montemayor, Benjamin N.; Woodland, Gracie; Barry, Adam E.
Alcohol is the most commonly used substance among American school-aged youth. It is often the initial substance adolescents try, and its use is linked to subsequent illicit substance use later in life. Alcohol use is associated with poorer academic performance and engagement in risky behaviors, potentially affecting future work and educational opportunities. Rather than substance-specific interventions, policies and strategies should focus on enhancing prevention and treatment infrastructure. Rural areas consistently show higher rates of hazardous alcohol use or alcohol-related harm. Public health strategies tailored to rural communities’ unique needs are essential. In-depth assessments of individual, community, and familial factors (e.g., religiosity, social norms, family relationships) should be conducted to inform targeted intervention and prevention efforts. Addressing alcohol-related challenges in rural communities requires tailored approaches that consider local context and individual factor
Hospital and Emergency Services in Rural Areas
(Texas A&M University, 2023) Côté, Murray J.; Shrestha, Aakriti
Rural America continues to face significant challenges in accessing hospital and emergency services. Through various combinations of policy and technology, considerable progress has been made in the breadth and delivery of services in rural communities. Ironically, the barriers that persist are consequences of being associated with rural regions. The pursuit of improving rural-based hospital and emergency services is made more difficult by limited healthcare resources, low population density, and residents with limited or no health insurance who also tend to have generally poorer health status relative to those in other, primarily urban, geographic areas. Optimistically, the growing and persistent attention being paid to rural America may ultimately lead to lower disparities and fewer challenges. The recognition of the rural-urban gaps coupled with innovations in delivery, such as REHs and telehealth, represent important and significant progress.

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