Federal Office of Rural Health Policy Briefs
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Item Analysis of an Innovative Approach to Target Rural Communities in Public Health Funding(2023-03) Callaghan, Timothy H.; Falia, Gogoal; Greer, Earl; Ramy, Maya; Washburn, David J.In 2021, the Centers for Disease Control (CDC) carved out $427 million in state funding to focus on combatting COVID-19 in rural communities as part of a multi-billion dollar national initiative to address COVID-19-related health disparities among at-risk and underserved populations. This brief explores the circumstances around this emphasis on rural America by interviewing relevant decision-makers and key stakeholders. The analysis indicated the funds were well supported by stakeholders and were being used in creative ways. It also allowed more rural stakeholders to be involved in public health decision making. Although it's too soon to evaluate the funds' impact on rural communities, and there have been some infrastructure and capacity challenges in using the funds, most stakeholders would encourage rural carve outs for future grant programs.Item Rural Healthy People 2030: Common Challenges, Rural Nuances(2023-05) Kassabian, Morgan; Shrestha, Aakriti; Callaghan, Timothy H.; Helduser, Janet; Horel, Scott; Johnson, Natasha; Kaspar, Savannah; Bolin, Jane; Ferdinand, Alva O.This study reports the findings of Rural Healthy People 2030, a companion piece to the Healthy People 2030 initiative with a focus on health priorities of rural populations. Data was collected from a survey given to rural stakeholders and identified the top 20 Healthy People priorities for rural America.Item 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.Item 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.Item 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.Item 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.Item 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.Item 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, JaneRural 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.Item 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, ZuleymaThis 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.Item 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.Item 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.Item Cancer Mortality in Rural America(2018-11) Callaghan, Timothy H.; Ferdinand, Alva O.; Towne Jr, Samuel D.; Akinlotan, Marvellous; Primm, Kristin; Bolin, JaneFor 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.Item 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, JaneAcross 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.Item Post-Acute Skilled Nursing Care Availability in Rural United States(2020-07) McMaughan, Darcy; Anikpo, Ifedioranma O.; Horel, Scott; Ozmetin, JenniferThis 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.Item 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.Item 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, JaneIt 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.Item 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.Item 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.