The Journal of Rural Health (J Rural Health)

Publications in this journal

• Article: Regional Differences in Prescribing Quality Among Elder Veterans and the Impact of Rural Residence.

  Brian C Lund, Mary E Charlton, Michael A Steinman, Peter J Kaboli
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  ABSTRACT: Purpose: Medication safety is a critical concern for older adults. Regional variation in potentially inappropriate prescribing practices may reflect important differences in health care quality. Therefore, the objectives of this study were to characterize prescribing quality variation among older adults across geographic region, and to compare prescribing quality across rural versus urban residence. Methods: Cross-sectional study of 1,549,824 older adult veterans with regular Veterans Affairs (VA) primary care and medication use during fiscal year 2007. Prescribing quality was measured by 4 indicators of potentially inappropriate prescribing: Zhan criteria drugs to avoid, Fick criteria drugs to avoid, therapeutic duplication, and drug-drug interactions. Frequency differences across region and rural-urban residence were compared using adjusted odds-ratios. Findings: Significant regional variation was observed for all indicators. Zhan criteria frequencies ranged from 13.2% in the Northeast to 21.2% in the South. Nationally, rural veterans had a significantly increased risk for inappropriate prescribing according to all quality indicators. However, regional analyses revealed this effect was limited to the South and Northeast, whereas rural residence was neutral in the Midwest and protective in the West. Conclusions: Significant regional variation in prescribing quality was observed among older adult veterans, mirroring recent findings among Medicare beneficiaries. The association between rurality and prescribing quality is heterogeneous, and relying solely on national estimates may yield misleading conclusions. Although we documented important variations in prescribing quality, the underlying factors driving these trends remain unknown, and they are a vital area for future research affecting older adults in both VA and non-VA health systems.
  The Journal of Rural Health 03/2013; 29(2):172-179.
• Article: The influence of rural versus urban residence on utilization and receipt of care for chronic low back pain.

  Adam P Goode, Janet K Freburger, Timothy S Carey
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  ABSTRACT: Purpose: (1) To describe demographic and health-related characteristics among rural/urban residents with chronic low back pain (LBP); (2) To determine if the utilization of diagnostics and treatments differs between rural and urban residents with chronic LBP; and (3) To determine the association between rural/urban residence and health care provider usage and if associations differ by race or gender. Methods: A 2006 cross-sectional telephone survey of a representative sample of North Carolina residents. Subjects with chronic LBP were questioned regarding their health and health care use. Wald and chi-square tests were used to determine differences between demographic and health-related characteristics of rural/urban residents. Logistic regression was used to determine the association between rural/urban residence and health care provider use. Differences in race or gender were explored with stratified analysis with a P < .10. Findings: 588 residents of North Carolina with self-reported chronic LBP sought care from a provider in the previous year. In bivariate analyses, when compared to urban residents, rural residents were younger, more likely to be uninsured, reported significantly higher levels of disability, and reported more depression/sadness. Rural residents were less likely to receive care from a rheumatologist (adjusted odds ratio [aOR] 0.47 [95% CI, 0.22-0.99]). Rural blacks were less likely to receive care from a physical therapist when compared to urban blacks (aOR 0.26 [95% CI, 0.07-0.87]). Conclusion: Despite similarities of high provider use, imaging and therapeutics, when compared to urban residents, rural residents reported higher levels of functional limitation and depression.
  The Journal of Rural Health 03/2013; 29(2):205-14.
• Article: The financial performance of rural hospitals and implications for elimination of the critical access hospital program.

  George M Holmes, George H Pink, Sarah A Friedman
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  ABSTRACT: Purpose: To compare the financial performance of rural hospitals with Medicare payment provisions to those paid under prospective payment and to estimate the financial consequences of elimination of the Critical Access Hospital (CAH) program. Methods: Financial data for 2004-2010 were collected from the Healthcare Cost Reporting Information System (HCRIS) for rural hospitals. HCRIS data were used to calculate measures of the profitability, liquidity, capital structure, and financial strength of rural hospitals. Linear mixed models accounted for the method of Medicare reimbursement, time trends, hospital, and market characteristics. Simulations were used to estimate profitability of CAHs if they reverted to prospective payment. Findings: CAHs generally had lower unadjusted financial performance than other types of rural hospitals, but after adjustment for hospital characteristics, CAHs had generally higher financial performance. Conclusions: Special payment provisions by Medicare to rural hospitals are important determinants of financial performance. In particular, the financial condition of CAHs would be worse if they were paid under prospective payment.
  The Journal of Rural Health 03/2013; 29(2):140-9.
• Article: Montana primary care providers' access to and satisfaction with pediatric specialists when caring for children with special health care needs.

  Rose Hardy, Patrick Vivier, Frederick Rivara, Sandford Melzer
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  ABSTRACT: Purpose: Primary care providers (PCPs) of children with special health care needs (CSHCN) in rural areas face challenges in accessing specialty care to support a patient-centered medical home. This study assessed the practice characteristics and attitudes regarding pediatric specialty care among Montana PCPs of CSHCN. Methods: We surveyed 433 Montana PCPs identified through a statewide registry. Demographic and practice information was collected, including the proportion of time spent on CSHCN care coordination. A 5-point Likert scale was used to calculate mean need scores for each pediatric specialty, access to these specialties, and barriers to care. Results were analyzed separately for pediatricians and family physicians, as well as rural and urban providers, using λ2, t tests, and Mann-Whitney tests. Results: Of the PCPs surveyed, 386 had a valid address and were currently practicing in Montana, 112 (29%) responded, and 91 provided care to CSHCN (averaged 29% of time spent in CSHCN care coordination). Child psychiatry (4.1) and developmental/behavioral pediatrics (3.7) were identified as the most needed specialties, yet they scored lowest in access to care (2.2 and 2.6, respectively). The most important rated specialist characteristics were quality (4.1), availability (3.5), and communication skills (2.8). Among the top barriers to care, lack of appropriate specialists was identified by 82% of PCPs. Conclusions: Specialty care delivery for CSHCN in rural areas such as Montana should focus on matching availability with the identified need for specialty services, and ensuring that systems of communication between PCPs and specialists support the care coordination function of PCPs.
  The Journal of Rural Health 03/2013; 29(2):224-32.
• Article: Trauma patients over-triaged to helicopter transport in an established midwestern state trauma system.

  Hayden L Smith, Richard A Sidwell
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  ABSTRACT: Purpose: To characterize helicopter transport use in a mature Midwestern trauma system located in a low population density state, examine characteristics of patients over-triaged to helicopter transport, and determine predictors of over-triage to helicopter transport. Methods: A retrospective observational study conducted using State Trauma Registry data for years 2008-2009. Study sample included patients with medical helicopter transportation. Bivariate analyses compared patients defined and not defined as over-triaged to helicopter transport. Multivariate regression was used to determine predictors of over-triage. Findings: Of the 2,084 helicopter-transported study patients, 552 (26%) were defined as over-triaged. Differences in patients based on over-triaged status included race, age, injury mechanism, injury type, and injury intent (P < .05). Multivariate-based significant predictors of over-triage were transfer status, patient age, and injury mechanism (P= .0223; <.0001; and .0007, respectively). Patients transported from scene had a greater odds (OR: 1.29; 95% confidence interval: 1.04, 1.60) of being over-triaged to helicopter transport than interfacility transfers. Younger patients were also more likely to be over-triaged. Interactions between patient age and injury mechanism demonstrated varied likelihoods for over-triage. Younger patients injured in falls were more likely over-triaged than younger patients injured in a motor vehicle crash or by other non-fall causes. Conclusion: Study data showed over-triage to helicopter transport was substantial in a mature trauma system. It is recommended that trauma systems develop and monitor compliance with criteria for appropriate use of air medical transport. These actions can assist in refinements to prehospital and interfacility transfer protocols.
  The Journal of Rural Health 03/2013; 29(2):132-9.
• Article: The metabolic syndrome: are rural residents at increased risk?

  Tushar Trivedi, Jihong Liu, Janice C Probst, Amy Brock Martin
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  ABSTRACT: Purpose: The purpose of this study was to estimate the differences in prevalence of metabolic syndrome and its individual components across rural-urban populations, as well as to determine the risk factors associated with metabolic syndrome and examine how they contribute toward rural-urban disparity.Methods: Data came from the 1999-2006 National Health and Nutrition Examination Survey, restricting to 6,896 participants aged 20 years or more with complete information. Metabolic syndrome was defined using the National Cholesterol Education Program's Adult Treatment Panel III criteria. Residence was measured at the census tract level using the Rural-Urban Commuting Area Codes. We estimated the prevalence of metabolic syndrome and its components by residence. Multiple logistic regression models were used to examine urban-rural differences after adjusting for sociodemographic, health, dietary, and lifestyle factors.Results: The prevalence of metabolic syndrome was higher in rural than urban residents (39.9% vs 32.8%), among both men (39.7% vs 33.3%) and women (40.2% vs 32.3%, respectively). The age and sex adjusted OR for metabolic syndrome in rural as compared to urban residents was 1.23 (95% CI, 1.02-1.49), which was attenuated to 1.06 (95% CI, 0.90-1.25) after adjusting for covariates. Older age, lower physical activity, higher screen time, higher meat intake, and skipping breakfast were associated with increased odds of metabolic syndrome.Conclusion: Rural dwelling was associated with higher prevalence of metabolic syndrome among adults in the Unites States, which can be attributed to the differences in demographic composition and obesity-related behavioral factors between urban and rural residents.
  The Journal of Rural Health 03/2013; 29(2):188-97.
• Article: Are primary care practices ready to become patient-centered medical homes?

  Fred A Ullrich, A Clinton Mackinney, Keith J Mueller
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  ABSTRACT: Purpose: To measure the readiness of rural primary care practices to qualify as patient-centered medical homes (PCMHs), one step toward participating in changes underway in health care finance and delivery. Methods: We used the 2008 Health Tracking Physician Survey to compare PCMH readiness scores among metropolitan and nonmetropolitan primary care practices. The National Committee on Quality Assurance (NCQA) assessment system served as a framework to assess the PCMH capabilities of primary care practices based on their services, processes, and policies. Findings: We found little difference between urban and rural practices. Approximately 41% of all primary care practices offer minimal or no PCMH services. We also found that large practices score higher on standards primarily related to information technology and care management. Conclusions: Achieving the benefits of the PCMH model in small rural practices may require additional national promotion, technical assistance, and financial incentives.
  The Journal of Rural Health 03/2013; 29(2):180-7.
• Article: Rural-urban differences in consumer governance at community health centers.

  Brad Wright
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  ABSTRACT: Context: Community health centers (CHCs) are primary care clinics that serve mostly low-income patients in rural and urban areas. They are required to be governed by a consumer majority. What little is known about the structure and function of these boards in practice suggests that CHC boards in rural areas may look and act differently from CHC boards in urban areas. Purpose: To identify differences in the structure and function of consumer governance at CHCs in rural and urban areas. Methods: Semistructured telephone interviews were conducted with 30 CHC board members from 14 different states. Questions focused on board members' perceptions of board composition and the role of consumers on the board. Findings: CHCs in rural areas are more likely to have representative boards, are better able to convey confidence in the organization, and are better able to assess community needs than CHCs in urban areas. However, CHCs in rural areas often have problems achieving objective decision-making, and they may have fewer means for objectively evaluating quality of care due to the lack of patient board member anonymity. Conclusions: Consumer governance is implemented differently in rural and urban communities, and the advantages and disadvantages in each setting are unique.
  The Journal of Rural Health 03/2013; 29(2):125-31.
• Article: Rural relevant quality measures for critical access hospitals.

  Michelle M Casey, Ira Moscovice, Jill Klingner, Shailendra Prasad
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  ABSTRACT: Purpose: To identify current and future relevant quality measures for Critical Access Hospitals (CAHs). Methods: Three criteria (patient volume, internal usefulness for quality improvement, and external usefulness for public reporting and payment reform) were used to analyze quality measures for their relevance for CAHs. A 6-member panel with expertise in rural hospital quality measurement and improvement provided input regarding the final measure selection. Findings: The relevant quality measures for CAHs include measures that are ready for reporting now and measures that need specifications to be finalized and/or a data reporting mechanism to be established. They include inpatient measures for specific medical conditions, global measures that address appropriate care across multiple medical conditions, and Emergency Department measures. Conclusions: All CAHs should publicly report on relevant quality measures. Acceptance of a single consolidated set of quality measures with common specifications for CAHs by all entities involved in regulation, accreditation, and payment; a phased process to implement the relevant measures; and the provision of technical assistance would help CAHs meet the challenge of reporting.
  The Journal of Rural Health 03/2013; 29(2):159-71.
• Article: Rural-Urban Differences in Health Services Utilization in the US-Mexico Border Region.

  Dejun Su, William Pratt, Jennifer Salinas, Rebeca Wong, José A Pagán
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  ABSTRACT: Purpose: Evaluate the association between driving distance to the US-Mexico border and rural-urban differences in the use of health services in Mexico by US border residents from Texas. Methods: Data for this study come from the Cross-Border Utilization of Health Care Survey, a population-based telephone survey conducted in the Texas border region in spring 2008. Driving distances to the border were estimated from the nearest border crossing station using Google Maps. Outcome measures included medication purchases, physician visits, dentist visits, and inpatient care in Mexico during the 12 months prior to the survey. A series of adjusted logit models were estimated after controlling for relevant confounding factors. Findings: The average driving distance to the nearest border crossing station among rural respondents was 4 times that of urban respondents (42.0 miles vs 10.3 miles [P < .001]). Rural respondents were more likely to be dissatisfied than urban respondents with the health care provided on the US side of the border, yet they were less likely to use health services in Mexico. Driving distance to the border largely explained the observed rural-urban differences in medication purchases from Mexico. In the case of inpatient care, however, rural respondents reported a higher utilization rate than urban respondents and this rural-urban difference became more pronounced after adjusting for the effect of driving distance to the border. Conclusions: Dissatisfaction with US health care services in rural communities in the US-Mexico border region seems to be compounded by the lack of access to health care services in Mexico due to travel distance constraints.
  The Journal of Rural Health 03/2013; 29(2):215-223.
• Article: Measuring the performance of critical access hospitals in missouri using data envelopment analysis.

  Shriniwas Gautam, Lanis Hicks, Thomas Johnson, Bhawani Mishra
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  ABSTRACT: Purpose: Rural hospitals are critical for access to health care, and for their contributions to local economies. However, many rural hospitals, especially critical access hospitals (CAHs) need to strive for more efficiency for continued viability. Routinely evaluating their performance, and providing feedback to management and policy makers, is therefore important. Method: Three measures of relative efficiency are estimated for CAHs in Missouri using an Input-oriented Data Envelopment Analysis with a variable returns to scale assumption and compared with the efficiency of other rural hospitals in Missouri using Banker's F-test. Using 30-day readmission rate as a measure of quality, CAHs are evaluated against efficiency-quality dimensions. Findings: CAHs in Missouri had a slight decline in average technical efficiency, but they had a slight gain in average cost efficiency in 2009 compared to 2006. More than half of the CAHs were neither economically nor technically efficient in both years. The relative efficiency of other rural hospitals was statistically higher than that of CAHs in Missouri. Conclusions: This study validates the finding of relative inefficiency of CAHs compared to other hospitals paid under the Prospective Payment System at a state level (Missouri). However, with considerable variation in socioeconomic as well as health care access indicators across states, a relative efficiency frontier may not be the only relevant indicator of value for the evaluation of the performance of CAHs. Access to health care and the impact on the local economy provided by these CAHs to the community are also critical indicators for more comprehensive performance evaluation.
  The Journal of Rural Health 03/2013; 29(2):150-8.
• Article: Health care utilization patterns for young children in rural counties of the I-95 corridor of South Carolina.

  James T McElligott, Andrea P Summer
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  ABSTRACT: Objective: The objective of this study was to assess health care utilization patterns for young children with Medicaid insurance in the rural counties of the I-95 corridor in South Carolina relative to other regions of the state. We hypothesize that young children received less well care and higher levels of tertiary care in the rural counties along the I-95 corridor (I-95) of South Carolina. Design/Methods: A Medicaid cohort of children less than 3 years of age was used to compare Early, Periodic, Diagnosis, Screening and Treatment (EPSDT) visits; preventable emergency department (ED) visits; and inpatient visits between I-95, other rural and urban county groupings. Results: The adjusted odds of a child having had 80% of the recommended EPSDT visits were reduced for I-95 compared to other rural counties. The odds of a preventable inpatient or ED visit were increased for all rural counties, with the highest rates in the other rural counties. Conclusions: Children accessed well care less in the I-95 corridor compared to other rural areas of South Carolina. Rural children accessed tertiary care more often than urban children, a finding most prominent outside the I-95 corridor, likely attributable to more available access of tertiary care in rural counties outside the I-95 corridor.
  The Journal of Rural Health 03/2013; 29(2):198-204.
• Article: Maternal Obesity and Gestational Weight Gain in Rural Versus Urban Dwelling Women in South Carolina.

  Alexa Gallagher, Jihong Liu, Janice C Probst, Amy B Martin, Jeffrey W Hall
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  ABSTRACT: Purpose: An unhealthy prepregnancy weight and/or gaining an inappropriate amount of weight during pregnancy increase the risk for poor pregnancy and birth outcomes. To our knowledge, no studies to date have examined differences in prepregnancy body mass index (BMI) and gestational weight gain (GWG) patterns by rurality. Methods: The 2004-2006 South Carolina birth certificate data (n = 132,795) were used. Rurality of residence was determined using Rural-Urban Commuting Area (RUCA) codes. Mothers were categorized as underweight (<18.5 kg/m(2) ), normal weight (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0) using their prepregnancy BMI and as having inadequate, adequate, or excessive GWG according to the Institute of Medicine's 2009 GWG guidelines. Chi-square tests and adjusted multinomial logistic regression were used in analysis. Findings: Rural women had higher odds of being overweight and obese compared to urban women. This relationship was found to be partially explained by the higher proportion of minorities living in rural areas. The relationship between GWG and residence type varied by BMI category. Specifically, among normal weight women, rural women had increased odds of inadequate GWG. Among overweight women, rural women had decreased odds of excessive GWG. In obese women, rural women had decreased odds of both inadequate and excessive GWG. Conclusions: Rural women were more likely to have an unhealthy prepregnancy weight than urban women. However, rural residence was found to be protective against unhealthy GWG in overweight and obese women. Future research exploring reasons for these findings and confirmation of these results in other populations is necessary.
  The Journal of Rural Health 01/2013; 29(1):1-11.
• Article: Rural roadway safety perceptions among rural teen drivers living in and outside of towns.

  Marizen Ramirez, Lisa Roth, Tracy Young, Corinne Peek-Asa
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  ABSTRACT: Purpose: To compare perceptions about rural road and general driving behaviors between teens who live in- and out-of-town from rural communities in Iowa. Methods: A cross-sectional survey was conducted with 160 teens anticipating their Intermediate License within 3 months upon enrollment into this study. Self-administered surveys were used to collect demographics and driving exposures (eg, frequency of driving, age when first drove unsupervised). Two Likert scales were included to measure agreement with safe driving behaviors on rural roads and general safe driving behaviors (eg, speeding, seat belt use). T-tests were calculated comparing mean composite scores between in- and out-of-town teens, and between mean rural road and general driving safety attitude scores. A linear regression multivariable model was constructed to identify predictors of the rural road score. Results: While the majority of teens endorsed rural road and general safe driving behaviors, up to 40% did not. Thirty-two percent did not believe the dangers of animals on rural roads, and 40% disagreed that exceeding the speed limit is dangerous. In-town teens were less safety conscious about rural road hazards with a significantly lower mean composite score (4.4) than out-of-town teens (4.6); mean scores for general driving behaviors were similar. Living out-of-town and owning one's own car were significant predictors of increased rural road safety scores. Conclusion: Rural, in-town teens have poorer safety attitudes about rural roadway hazards compared with out-of-town teens. Interventions that involve education, parental supervision, and practice on rural roads are critical for preventing teen crashes on rural roads.
  The Journal of Rural Health 01/2013; 29(1):46-54.
• Article: Understanding the landscape: promoting health for rural individuals after tertiary level cardiac revascularization.

  Barbara Pesut, Carol Laberge, Richard Sawatzky, Julia Mallinson, Kathy Rush
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  ABSTRACT: Purpose: The purpose of this pilot study was to describe the needs and experiences of rural individuals commuting to an urban center for percutaneous coronary intervention (PCI). Methods: Data were analyzed from a "Patient Adherence and Satisfaction Survey" conducted by telephone as part of a quality improvement focus, and supplemented with in-depth semi-structured interviews with rural patients following PCI. Findings: Both urban and rural patients after PCI experienced few complications, had made some attempts to reduce tobacco usage, and were highly satisfied with explanations of their treatment and their overall treatment experience. Patients in rural settings were more likely to experience chest pain at least rarely following their surgery than people in urban settings (P < .05). Data on participation in cardiac rehabilitation (CR) showed no significant differences between urban and rural dwellers. Four themes emerged from the interviews: standards of care during treatment; transportation; local resources and community support; and lifestyle changes. Although patients were highly satisfied with standards of care during acute treatment, there were unmet needs in relation to transportation and lifestyle changes. Conclusion: Transitions between rural communities and urban centers and rural adaptations of secondary prevention programs require more attention in health service delivery. Further research is required to better understand potential variations in chest pain patterns between urban and rural residents.
  The Journal of Rural Health 01/2013; 29(1):88-96.
• Article: Availability of emergency contraception in rural and urban pharmacies in kansas.

  Fernand D Samson, Rebecca Loren, Nicki Downing, Sarah Schroeppel, Patricia J Kelly, Megha Ramaswamy
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  ABSTRACT: Purpose: Determine availability of emergency contraception (EC) at rural and urban pharmacies in Kansas. Methods: A sample of 201 Kansas pharmacies was selected using a random integer generator. We measured ability to dispense EC within 24 hours and whether it was in stock at the time of the survey call. We examined EC availability based on geographic differences and pharmacy type. Findings: Of the sample, 186 pharmacists agreed to be interviewed. Of these, 19% (n = 36) were unable to provide EC within 24 hours. There were essentially no differences in availability of EC between rural (75% could dispense in 24 hours) and urban pharmacies (85% could dispense in 24 hours) (P= .105). Corporate pharmacies were more likely to be able to provide EC within 24 hours compared to independent pharmacies (OR = 3.79, CI 1.71-8.43). Thirty-one percent (n = 57) of pharmacists did not carry EC at the time of the survey call. With this sample, urban pharmacies were more than twice as likely to report carrying EC compared to rural pharmacies (OR = 2.47, CI 1.31-4.68), and corporate pharmacies were also more likely to report carrying EC compared to independent pharmacies (OR = 7.77, CI 3.72-16.21). Conclusions: In a sample of Kansas pharmacies, there were no differences between rural and urban pharmacies in 24-hour EC availability; however, there were differences in those who stocked EC at the time of the survey call. Corporate pharmacies were more likely to dispense EC within 24 hours and have it in stock compared to independent pharmacies, suggesting differences in availability of EC.
  The Journal of Rural Health 01/2013; 29(1):113-8.
• Article: Recruiting rural participants for a telehealth intervention on diabetes self-management.

  Sheridan Miyamoto, Stuart Henderson, Heather Young, Deborah Ward, Vanessa Santillan
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  ABSTRACT: Purpose: Recruiting rural and underserved participants in behavioral health interventions is challenging. Community-based recruitment approaches are effective, but they are not always feasible in multisite, diverse community interventions. This study evaluates the feasibility of a rapid, multisite approach that uses rural clinic site coordinators to recruit study participants. The approach allows for rural recruitment in areas where researchers may not have developed long-term collaborative relationships. Methods: Adults with diabetes were recruited from rural Federally Qualified Health Center (FQHC) clinics. Recruitment feasibility was assessed by analyzing field notes by the project manager and health coaches, and 8 in-depth, semistructured interviews with clinic site coordinators and champions, followed by thematic analysis of field notes and interviews. Findings: Forty-seven rural sites were contacted to obtain the 6 sites that participated in the study. On average, sites took 14 days to commit to study participation. One hundred and twenty-one participants were acquired from letters mailed to eligible participants and, in some sites, by follow-up phone calls from site coordinators. Facilitators and deterrents affecting study recruitment fell into 4 broad categories-study design, site, site coordinator, and participant factors. Conclusion: The rapid multisite approach led to quick and efficient recruitment of clinic sites and participants. Recruitment success was achieved in some, but not all, rural sites. The study highlights the opportunities and challenges of recruiting rural clinics and rural, underserved participants in multisite research. Suggestions are provided for improving recruitment for future interventions.
  The Journal of Rural Health 01/2013; 29(1):69-77.
• Article: Barriers to cancer clinical trial participation among american Indian and alaska native tribal college students.

  Debra Sprague, Joan Russo, Donna L Lavallie, Dedra Buchwald
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  ABSTRACT: Purpose: American Indians and Alaska Natives (AIs/ANs) have some of the highest cancer-related mortality rates of all US racial and ethnic groups, but they are underrepresented in clinical trials. We sought to identify factors that influence willingness to participate in cancer clinical trials among AI/AN tribal college students, and to compare attitudes toward clinical trial participation among these students with attitudes among older AI/AN adults. Methods: Questionnaire data from 489 AI/AN tribal college students were collected and analyzed along with previously collected data from 112 older AI/AN adults. We examined 10 factors that influenced participation in the tribal college sample, and using chi-square analysis and these 10 factors, we compared attitudes toward research participation among 3 groups defined by age: students younger than 40, students 40 and older, and nonstudent adults 40 and older. Findings: About 80% of students were willing to participate if the study would lead to new treatments or help others with cancer in their community, the study doctor had experience treating AI/AN patients, and they received payment. Older nonstudent adults were less likely to participate on the basis of the doctor's expertise than were students (73% vs 84%, P = .007), or if the study was conducted 50 miles away (24% vs 41%, P= .001). Conclusions: Finding high rates of willingness to participate is an important first step in increasing participation of AIs/ANs in clinical trials. More information is needed on whether these attitudes influence actual behavior when opportunities to participate become available.
  The Journal of Rural Health 01/2013; 29(1):55-60.
• Article: Understanding and addressing barriers to implementation of environmental and policy interventions to support physical activity and healthy eating in rural communities.

  Ellen K Barnidge, Catherine Radvanyi, Kathleen Duggan, Freda Motton, Imogene Wiggs, Elizabeth A Baker, Ross C Brownson
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  ABSTRACT: Purpose: Rural residents are at greater risk of obesity than urban and suburban residents. Failure to meet physical activity and healthy eating recommendations play a role. Emerging evidence shows the effectiveness of environmental and policy interventions to promote physical activity and healthy eating. Yet most of the evidence comes from urban and suburban communities. The objectives of this study were to (1) identify types of environmental and policy interventions being implemented in rural communities to promote physical activity or healthy eating, (2) identify barriers to the implementation of environmental or policy interventions, and (3) identify strategies rural communities have employed to overcome these barriers. Methods: Key informant interviews with public health professionals working in rural areas in the United States were conducted in 2010. A purposive sample included 15 practitioners engaged in planning, implementing, or evaluating environmental or policy interventions to promote physical activity or healthy eating. Findings: Our findings reveal that barriers in rural communities include cultural differences, population size, limited human capital, and difficulty demonstrating the connection between social and economic policy and health outcomes. Key informants identified a number of strategies to overcome these barriers such as developing broad-based partnerships and building on the existing infrastructure. Conclusion: Recent evidence suggests that environmental and policy interventions have potential to promote physical activity and healthy eating at the population level. To realize positive outcomes, it is important to provide opportunities to implement these types of interventions and document their effectiveness in rural communities.
  The Journal of Rural Health 01/2013; 29(1):97-105.
• Article: Off-Road Vehicle Ridership and Associated Helmet Use in Canadian Youth: An Equity Analysis.

  Colleen M Davison, Wendy Thompson, Michael Torunian, Patricia Walsh, Steven McFaull, William Pickett
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  ABSTRACT: Purpose: In North America, the use of off-road vehicles by young people is increasing, as are related injuries and fatalities. We examined the prevalence of off-road ridership and off-road helmet use in different subgroups of Canadian youth in order to better understand possible inequities associated with these health risk behaviors. Methods: Data came from Cycle 6 (2009-2010) of the WHO Health Behavior in School-Aged Children Study (HBSC). Participants (n = 26,078) were young people from grades 6-10 in 436 Canadian schools. Students were asked, for a 12-mo recall period, how frequently they rode off-road vehicles and how often they wore a helmet while riding. Engagement in off-road ridership and helmet use were estimated by age group, gender, urban-rural geographic location, socioeconomic status, and how long participants had lived in Canada. Findings: About half of the sample reported riding off-road vehicles (12,750; 52%). Among riders, 5,691 (45%) always wore helmets. Riders were more often older students, male and born in Canada. Students in rural areas and small towns were much more likely to ride off-road vehicles than their urban peers (RR, 95% CI: 1.28 [1.23-1.33]). Helmet use was less common among females, new immigrants, older students, and those in lower socioeconomic groups. There was little reported difference in helmet use by urban-rural location. Conclusions: Risks associated with the use of off-road vehicles and with nonhelmet use are not equitably distributed across Canadian youth. Factors characterizing off-road ridership (notably urban-rural location) are distinct from factors for helmet use. Preventive interventions should target population subgroups.
  The Journal of Rural Health 01/2013; 29(1):39-45.