PURPOSE:Understanding rural-urban disparities in patient satisfaction is critical to identify gaps for improvement in patient-centered care and tailor interventions to specific patient needs, especially those in the Frontier and Remote areas (FAR). This study aimed to examine disparities in patient perceptions of care between urban, rural non-FAR, and FAR hospitals between 2014 and 2019.METHODS:This is a retrospective longitudinal study using 2014-2019 Hospital Consumer Assessment of Healthcare Providers and Systems data linked to American Hospital Annual Survey data (3,524 hospitals in 2014 and 3,440 hospitals in 2019). Multivariable linear regression models were used to identify differential trends in patient perceptions of care by hospital rurality over 2014-2019, adjusting hospital- and county-level characteristics.FINDINGS:In 2014, patients at rural non-FAR and FAR hospitals had lower percentages of willingness to definitely recommend these hospitals than urban hospitals (average percentage difference, 95% CI: -4.0% [-4.5%, -3.5%]; -2.0% [-2.8%, -1.2%]); yet, over the study period, rural hospitals experienced steeper increases in patient willingness to recommend (0.2% [0.07%, 0.4%]; 0.4% [0.08%, 0.7%]). FAR hospitals also showed improvements in patient experience in a clean environment, communication with nurses, communication about medicines, and responsiveness of staff. Communication with doctors showed slight decreases across hospital locations.CONCLUSIONS:Patient perceptions of care were generally improved in all US hospitals from 2014 to 2019, except communications with doctors. These findings highlight the potential for enhancing patient satisfaction and experience in urban hospitals and suggest the need to improve patient willingness to recommend in rural FAR hospitals.

Prior studies examining the association between childhood sexual abuse (CSA) and subjective cognitive decline (SCD) are limited. The aim of this study was to examine the racial/ethnic and sexual orientation disparities in the association between CSA and SCD. Using data from the 2019 Behavioral Risk Factor Surveillance System Survey, crude and multivariable logistic regression models were used to determine the association between CSA and SCD adjusting for sociodemographic characteristics, diabetes, hypertension, and depression. There were statistically significant differences in CSA status by age, gender, income, education, employment, and health status (depression). Black and Hispanic/Latine respondents had a stronger relationship between CSA and SCD compared to White populations. Also, sexual minority populations had a stronger relationship between CSA and SCD compared to heterosexual populations. Health disparities exist in the association between CSA and SCD. Trauma-informed interventions should be implemented among affected populations.

INTRODUCTION:The COVID-19 pandemic has disrupted cancer care, but it is unknown how the pandemic has affected care in Medicare-certified rural health clinics (RHCs) where cancer prevention and screening services are critical for their communities. This study examined how the provision of these cancer services changed pre- and peri-pandemic overall and by RHC type (independent and provider-based).METHODS:We administered a cross-sectional survey to a stratified random sample of RHCs to assess clinic characteristics, pandemic stressors, and the provision of cancer prevention and control services among RHCs pre- and peri-pandemic. We used McNemar's test and Wilcoxon signed rank tests to assess differences in the provision of cancer prevention and screening services pre- and peri-pandemic by RHC type.RESULTS:Of the 153 responding RHCs (response rate of 8%), 93 (60.8%) were provider-based and 60 (39.2%) were independent. Both RHC types were similar in their experience of pandemic stressors, though a higher proportion of independent RHCs reported financial concerns and challenges obtaining personal protective equipment. Both types of RHCs provided fewer cancer prevention and screening services peri-pandemic-5.8 to 4.2 for provider-based and 5.3 to 3.5 for independent (P<.05 for both). Across lung, cervical, breast, and colorectal cancer-related services, the proportion of both RHC groups providing services dropped peri-pandemic.DISCUSSION:The pandemic's impact on independent and provider-based RHCs and their patients was considerable. Going forward, greater resources should be targeted to RHCs-particularly independent RHCs-to ensure their ability to initiate and sustain evidence-based prevention and screening services.

Examining the current incidence rates of HIV and STIs among racial and ethnic minority and rural residents is crucial to inform and expand initiatives and outreach efforts to address disparities and minimize the health impact of these diseases. A retrospective, cross-sectional study was conducted using Medicaid administrative claims data over a 2-year period (July 2019-June 2021) in South Carolina. Our main outcomes of interest were claims for chlamydia, gonorrhea, syphilis, and HIV. Any beneficiary with at least one claim for a relevant diagnosis throughout the study period was considered to have one of these diseases. Descriptive analyses and multivariable regression models were used to estimate the association between STIs, HIV, race and ethnicity, and rurality. Overall, 158,731 Medicaid beneficiaries had at least one medical claim during the study period. Most were female (86.6%), resided in urban areas (66.6%), and were of non-Hispanic Black race/ethnicity (42.6%). In total, 6.3% of beneficiaries had at least one encounter for chlamydia, 3.2% for gonorrhea, 0.5% for syphilis, and 0.8% for HIV. In multivariable models, chlamydia, gonorrhea, and HIV claims were significantly associated with non-Hispanic Black or other minority race/ethnicity compared to non-Hispanic white race/ethnicity. Rural residents were more likely to have a claim associated with chlamydia and gonorrhea compared to urban residents. The opposite was observed for syphilis and HIV. Providing updated evidence on disparities in STIs and HIV among racial/ethnic minority and rural populations in a southern state is essential for shaping state Medicaid policies to address health disparities.

Purpose The present study examines the association between rurality and positive childhood experiences (PCEs) among children and adolescents across all 50 states and the District of Columbia. Recent work has quantified the prevalence of PCEs at the national level, but these studies have been based on public use data files, which lack rurality information for 19 states. Methods Data for this cross-sectional analysis were drawn from 2016 to 2018 National Survey of Children's Health (NSCH), using the full data set with restricted geographic data (n = 63,000). Descriptive statistics and bivariate analyses were used to calculate proportions and unadjusted associations. Multivariable regression models were used to examine the association between residence and the PCEs that were significant in the bivariate analyses. Findings Rural children were more likely than urban children to be reported as having PCEs: volunteering in their community (aOR 1.29; 95% CI 1.18-1.42), having a guiding mentor (aOR 1.75; 95% CI 1.45-2.10), residing in a safe neighborhood (aOR 1.97; 95% CI 1.54-2.53), and residing in a supportive neighborhood (aOR 1.10; 95% CI 1.01-1.20) than urban children. Conclusions The assessment of rural-urban differences in PCEs using the full NSCH is a unique opportunity to quantify exposure to PCEs. Given the higher baseline rate of PCEs in rural than urban children, programs to increase opportunities for PCEs in urban communities are warranted. Future research should delve further into whether these PCEs translate to better mental health outcomes in rural children.

Background Increasing rates of bacterial sexually transmitted infections (STIs) may lead to increased HIV rates, as the STI and HIV epidemics are syndemic. Centers for Disease Control and Prevention guidelines recommend including extragenital (i.e., rectal and/or pharyngeal) STI screenings for certain populations at increased risk of STIs and concurrent infections with HIV. Methods A descriptive study was conducted by interviewing staff members from 4 rural primary care clinics in areas of high need for STI and HIV services in South Carolina. Qualitative data about their clinical practices in 2021 were obtained. The primary outcome was to determine the awareness and availability of health care services associated with STI and HIV care in these locations. Results Clinics in target counties provided limited STI and HIV testing and treatment services, especially for populations at risk of infection, indicating the need for additional clinical training and professional development for all clinic staff. Specifically, only 1 of 4 clinics provided extragenital STI testing, and no clinics reported prescribing preexposure prophylaxis. Conclusions Rural primary care clinics can fill important gaps in the availability of STI and HIV services with appropriate support and incentives. Findings from this study may aid in facilitating policy (state Medicaid agency) and program (state health department) decisions related to STI and HIV testing and treatment.

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BACKGROUND:The 2009 Health Information Technology for Economic and Clinical Health Act sets three stages of Meaningful Use requirements for the electronic health records incentive program. Health information exchange (HIE) technologies are critical in the meaningful use of electronic health records to support patient care coordination. However, HIE use trends and barriers remain unclear across hospitals in South Carolina (SC), a state with the earliest HIE implementation. OBJECTIVE:This study aims to explore changes in the proportion of HIE participation and factors associated with HIE participation, and barriers to exchange and interoperability across SC hospitals. METHODS:This study derived data from a longitudinal data set of the 2014-2020 American Hospital Association Information Technology Supplement for 69 SC hospitals. The primary outcome was whether a hospital participated in HIE in a year. A cross-sectional multivariable logistic regression model, clustered at the hospital level and weighted by bed size, was used to identify factors associated with HIE participation. The second outcome was barriers to sending, receiving, or finding patient health information to or from other organizations or hospital systems. The frequency of hospitals reporting each barrier related to exchange and interoperability were then calculated. RESULTS:Hospitals in SC have been increasingly participating in HIE, improving from 43% (24/56) in 2014 to 82% (54/66) in 2020. After controlling for other hospital factors, teaching hospitals (adjusted odds ratio [AOR] 3.7, 95% CI 1.0-13.3), system-affiliated hospitals (AOR 6.6, 95% CI 3.2-13.7), and rural referral hospitals (AOR 8.0, 95% CI 1.2-53.4) had higher odds to participate in HIE than their counterparts, whereas critical access hospitals (AOR 0.1, 95% CI 0.02-0.6) were less likely to participate in HIE than their counterparts reimbursed by the prospective payment system. Hospitals with greater ratios of Medicare or Medicaid inpatient days to total inpatient days also reported higher odds of HIE participation. Despite the majority of hospitals reporting HIE participation in 2020, barriers to exchange and interoperability remained, including lack of provider contacts (27/40, 68%), difficulty in finding patient health information (27/40, 68%), adapting different vendor platforms (26/40, 65%), difficulty matching or identifying same patients between systems (23/40, 58%), and providers that do not typically exchange patient data (23/40, 58%). CONCLUSIONS:HIE participation has been widely adopted in SC hospitals. Our findings highlight the need to incentivize optimization of HIE and seamless information exchange by facilitating and implementing standardization of health information across various HIE systems and by addressing other technical issues, including providing providers' addresses and training HIE stakeholders to find relevant information. Policies and efforts should include more collaboration with vendors to reduce platform compatibility issues and more user engagement and technical training and support to facilitate effective, accurate, and efficient exchange of provider contacts and patient health information.

OBJECTIVE There has been limited examination of how community-level supports may influence oral health metrics among children. The purpose of our study is to examine the association between two types of community-level positive childhood experiences and oral healthcare and oral health outcomes among children ages 6 to 17 years of age. METHODS This study uses a cross-sectional data set from the 2018-2019 National Survey of Children's Health. Two oral health metrics were used: preventive dental care, measured as one or more preventive dental visits in the past 12 months, and tooth decay, measured as tooth decay or cavities in the last 12 months. To quantify living in safe, stable, equitable environments, questions on residing in a safe and supportive neighborhood were used. Descriptive statistics and bivariate analyses were used to calculate frequencies, proportions, and unadjusted associations for each variable (n = 40,290). Multivariable logistic regression models were used. RESULTS In an adjusted analysis, children who lived in a supportive neighborhood had a higher likelihood of receiving a preventive dental visit than children who did not live in a supportive neighborhood (aOR 1.41; 95% CI 1.21-1.65). Children who lived in a safe neighborhood were less likely to have tooth decay than children who did not live in a safe neighborhood (aOR 0.75; 95% CI 0.65-0.86). CONCLUSIONS The findings from this study highlight the role of social structures in tightening the safety net for oral healthcare in children.

INTRODUCTION Rural populations have less access to cancer care services and experience higher cancer mortality rates than their urban counterparts, which may be exacerbated by hospital closures. Our objective was to examine the impact of hospital closures on access to cancer-relevant hospital services across hospital service areas (HSAs). METHODS We used American Hospital Association survey data from 2008 to 2017 to examine the change in access to cancer-related screening and treatment services across rural HSAs that sustained hospitals over time, experienced any closures, or had all hospitals close. We performed a longitudinal analysis to assess the association between hospital closure occurrence and maintenance or loss of cancer-related service lines accounting for hospital and HSA-level characteristics. Maps were also developed to display changes in the availability of services across HSAs. RESULTS Of the 2,014 rural HSAs, 3.8% experienced at least 1 hospital closure during the study period, most occurring in the South. Among HSAs that experienced hospital closure, the loss of surgery services lines was most common, while hospital closures did not affect the availability of overall oncology and radiation services. Screening services either were stable (mammography) or increased (endoscopy) in areas with no closures. DISCUSSION Rural areas persistently experience less access to cancer treatment services, which has been exacerbated by hospital closures. Lack of Medicaid expansion in many Southern states and other policy impacts on hospital financial viability may play a role in this. Future research should explore the impact of closures on cancer treatment receipt and outcomes.

Positive childhood experiences (PCEs) promote healthy social development, improve overall wellness, and help to moderate and prevent exposure to adverse childhood experiences. There has been limited research examining the association between positive childhood experiences and overweight or obesity status in children. The purpose of this study was to examine whether experiencing positive childhood experiences are associated with lower rates of overweight or obesity status in children between 10 and 17 years of age, using cross-sectional data from the 2018-2019 National Survey of Children's Health (n = 28,771), a nationally representative mail and online survey. Frequencies, proportions, and unadjusted associations for each variable were calculated using descriptive statistics and bivariate analyses. To examine the association between overweight or obesity and PCEs, multivariable regression models were used. Compared to children who were underweight or had a healthy weight, children who were overweight or obese were less likely to: participate after school activities (78.1%, p < 0.0001), volunteer in their community, school, or church (45.6%, p < 0.0001), have a mentor they feel comfortable going to for guidance (87.0%, p = 0.02), live in a safe neighborhood (61.3%, p < 0.0001), live in a supportive neighborhood (50.4%, p < 0.0001), and to live with a resilient family (78.3%; p = 0.0099). In adjusted analysis, among children exposed to two or more ACEs, children residing in a supportive neighborhood were less likely to be overweight or obese (aOR 0.87; 0.77-0.98). Our findings suggest that certain PCEs may mitigate overweight and obesity when children have experienced at least some childhood trauma.

Interactive caregiving practices can be protective for the development of the brain in early childhood, particularly for children experiencing poverty. There has been limited research examining the prevalence of interactive caregiving practices in early childhood at the population level across the U.S. The purpose of this study was to describe the prevalence of three interactive caregiver activities: (1) reading, (2) telling stories/singing songs, and (3) eating a meal together, using the 2017-2018 National Survey of Children's Health, among a sample of children age five and younger, and to examine the relationship between these interactive caregiving practices across income levels and by selected potentially confounding household characteristics. Children living in families with incomes below the federal poverty level had lower odds of being read to every day compared to children living in families with incomes at 400% or more above the federal poverty level (aOR 0.70; 95% CI 0.53-0.92). Children living in families within incomes at 100-199% of the federal poverty level had lower odds of being sung to and told stories to every day than children living in families with incomes at 400% or above the federal poverty level (aOR 0.62; 95% CI 0.50-0.78).These findings have long-term implications for children, as interactive caregiving practices are known to improve cognitive activities such as language development, which is associated with educational attainment into adulthood. Finding ways to increase the adoption of interactive caregiving practices may be one way to mitigate disparities in education, especially among families experiencing poverty.

Examining how spatial access to health care varies across geography is key to documenting structural inequalities in the United States. In this article and the accompanying StoryMap, our team identified ZIP Code Tabulation Areas (ZCTAs) with the largest share of minoritized racial and ethnic populations and measured distances to the nearest hospital offering emergency services, trauma care, obstetrics, outpatient surgery, intensive care, and cardiac care. In rural areas, ZCTAs with high Black or American Indian/Alaska Native representation were significantly farther from services than ZCTAs with high White representation. The opposite was true for urban ZCTAs, with high White ZCTAs being farther from most services. These patterns likely result from a combination of housing policies that restrict housing opportunities and federal health policies that are based on service provision rather than community need. The findings also illustrate the difficulty of using a single metric-distance-to investigate access to care on a national scale.

PURPOSERecent studies suggest that Federally Qualified Health Centers (FQHC) may be expanding their provision of primary care in rural communities that experience a hospital loss. Whether these trends are different from rural areas not being affected by rural hospital closures is unknown.METHODSData included Centers for Medicare and Medicaid Services Provider of Services files, the Cecil G. Sheps hospital closure database, and American Community Survey estimates. Changes in straight-line distances to the nearest FQHC and rural health clinic (RHC) were compared between areas affected and unaffected by a rural hospital closure in a matched case control study design using an interrupted time series model.FINDINGSThere was no instantaneous percentage point increase in FQHC (2.41, 95% CI -0.79 to 5.60, P .140) or RHC (3.27, 95% CI -1.12 to 7.67, P .144) access following hospital closures compared to changes in access occurring in other rural areas. On average, rural ZIP codes affected by hospital closures exhibited a 0.84 percentage point increase in FQHC access over time (95% CI 0.40-1.28, P .000), but similar trends were also found within unaffected ZIP codes classified as small rural areas.CONCLUSIONSRural areas impacted by hospital closures did not experience an increase in proximity to FQHCs or RHCs relative to changes in access occurring in other rural areas. Over time, most rural areas are seeing an increase in access to FQHCs and RHCs. Policies are needed to incentivize primary care providers to target geographic areas experiencing a hospital closure.

OBJECTIVES:Educational attainment has been demonstrated as a protective factor for the physical and mental health of children into adulthood, yet there has been limited research on the association between positive childhood experiences (PCEs) and school success. The purpose of this study is to examine the associations between PCEs and challenges to school success.METHODS:This cross-sectional study used data of 33,450 children from the 2017-2018 National Survey of Children's Health to examine PCEs and two challenges to school success (school absenteeism and repeated grades), using multivariable logistic regression analysis.RESULTS:The most prevalent types of PCEs were mentor for advice or guidance (89.8%), family resilience (81.1%), and after-school activity participation (79.8%). Children who participated in after-school activities had lower odds of reported school absenteeism (aOR 0.59; 95% CI 0.46-0.76) and repeating a grade (aOR 0.75; 95% CI 0.59-0.97) than their counterparts. Children who shared ideas with their caregiver had lower odds of repeating a grade (aOR 0.78; 95% CI 0.63-0.97) than children who did not share ideas with their caregiver. Children who lived in a supportive neighborhood were less likely to have reported school absenteeism than children who did not live in a supportive neighborhood (aOR 0.77; 95% CI 0.60-0.98).CONCLUSIONS FOR PRACTICE:Participation in after-school activities had optimal associations with both school absenteeism and repeated grade, suggesting its potential protective effect for school success. Promoting PCEs at the school, family, and community levels may help address school absenteeism and grade retention.

One in every twenty-five persons in America is a racial/ethnic minority who lives in a rural area. Our objective was to summarize how racism and, subsequently, the social determinants of health disproportionately affect rural racial/ethnic minority populations, provide a review of the cancer disparities experienced by rural racial/ethnic minority groups, and recommend policy, research, and intervention approaches to reduce these disparities. We found that rural Black and American Indian/Alaska Native populations experience greater poverty and lack of access to care, which expose them to greater risk of developing cancer and experiencing poorer cancer outcomes in treatment and ultimately survival. There is a critical need for additional research to understand the disparities experienced by all rural racial/ethnic minority populations. We propose that policies aim to increase access to care and healthcare resources for these communities. Further, that observational and interventional research should more effectively address the intersections of rurality and race/ethnicity through reduced structural and interpersonal biases in cancer care, increased data access, more research on newer cancer screening and treatment modalities, and continued intervention and implementation research to understand how evidence-based practices can most effectively reduce disparities among these populations.

Objective: With declining numbers of obstetrician-gynecologists operating in rural areas across the United States, primary care providers have stepped in to fill contraceptive service gaps. Many of these providers operate in Rural Health Clinics; however, little is known about the provision of contraception in these clinics. Methods: This exploratory qualitative descriptive study used a purposive sampling strategy to recruit South Carolina Rural Health Clinic providers from across regions and income levels. Eleven providers participated in semi-structured, in-person interviews. Contraceptive care practices were identified using a combination of inductive and deductive coding. Results: Participants described their typical contraceptive patient as a low-income woman under 22 years. While providers were open to providing contraception, their on-site services were limited. Each included clinic offered the oral contraceptive pill and the shot, but only one offered the implant, and none offered the intrauterine device. Conclusion: Rural Health Clinic providers have limited capacity to offer a full range of contraception due to financial, training, and staffing constraints. Despite these limitations, Rural Health Clinics remain a contact point that helps meet national recommendations for increasing access to reproductive health services for rural women. Efforts to increase access to contraceptive care for rural women must include resources for these providers.

The postulate that the colours observed on a Benham's top (Fechner-Benham subjective colour) may be induced in a static flickering achromatic stimulus display was investigated. The initial experiment showed that to evoke the colours, the stimulus field must comprise at least two adjacent flickering regions. A range of subjective colours were measured using the binocular matching technique. Further measurements showed that a full gamut of subjective colour could be induced from two adjacent light pulses, the temporal separation determining the colour seen. The spatial features of Fechner-Benham subjective colour inducing stimuli were also investigated.

Background Chlamydia, gonorrhea, and syphilis are common, treatable sexually transmitted infections (STIs) that are highly prevalent in the general US population. Costs associated with diagnosing and treating these conditions for individual states' Medicaid participants are unknown. The purpose of this study was to estimate the cost of screening and treatment for 3 common STIs for state Medicaid program budgets in Maryland and South Carolina. Methods A retrospective, cross-sectional study was conducted using Medicaid administrative claims data over a 2-year period. Claims were included based on the presence of one of the 3 study conditions in either diagnosis or procedure codes. Descriptive analyses were used to characterize the participant population and expenditures for services provided. Results Total Medicaid expenditures for STI care in state fiscal years 2016 and 2017 averaged $43.5 million and $22.3 million for each year in Maryland and South Carolina, respectively. Maryland had a greater proportion of costs associated with outpatient hospital and laboratory settings. Costs for care provided in the emergency department were highest in South Carolina. Conclusions Diagnosis and treatment of commonly reported STIs may have a considerable financial impact on individual state Medicaid programs. Public health activities directed at STI prevention are important tools for reducing these costs to states.