Utilizing PRISM and RE-AIM to implement and evaluate the Rural Telementoring Training Center (RTTC) for health care workforce development in rural communities.

Introduction: Amid rural health worker shortages and hospital closures, it is imperative to build and maintain the local workforce. Telementoring (TM) or technology-enabled mentoring, is a tool for improving health care quality and access by increasing workforce capacity and support. The national Rural Telementoring Training Center (RTTC) was developed to compile and disseminate TM best practices by delivering free training, tools, and technical assistance to support the implementation, sustainability, and evaluation of new and current TM programs for rural health workers. This paper details how the Practical, Robust Implementation and Sustainability Model (PRISM) was used to understand the context that shaped implementation as well as how Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) was concurrently applied to frame outcomes. Methods: The RTTC has three implementation strategies: outreach, training and technical assistance (TTA), and a Quality Measure Toolkit. Ongoing periodic reflections with the RTTC team, informed by PRISM, were collected, as were RE-AIM outcomes. Central to this design was the continuous review of incoming data in team meetings to inform programmatic changes by identifying challenges and applying modifications to strategies in real time. Results: Major implementation changes discussed during reflections included providing timely and relevant messaging through various platforms, streamlining and customizing a TTA approach, and offering different options for accessing the Toolkit. The outreach strategy resulted in high Reach across the US, with over 300 organizations contacted. The effectiveness of the RTTC was demonstrated by counts of people engaging with outreach (ex. over 8,300 impressions on LinkedIn), the website (over 6,400 views), and e-bursts (33% open rate). Moreover, there were 32 TTA requests and 70 people accessing the Toolkit. Adoption was demonstrated by 27 people participating in TTA and 14 individuals utilizing the Toolkit. Discussion: The integration of PRISM and RE-AIM frameworks promoted a holistic implementation and evaluation plan. Using PRISM, the RTTC team was able to reflect on the implementation strategies through the lens of contextual factors and make rapid programmatic changes within team meetings. That process resulted in outcomes framed by RE-AIM. The integration of two frameworks in tandem provided an adaptive and comprehensive approach to implementing a large-scale, national program.

A Partnership Between Rural EMS and AT&T FirstNet to Provide Tele-emergency Care.

This report from the field describes a partnership between an academic medical center emergency department, rural emergency medical services, and AT&T FirstNet, a nationwide high-speed broadband network for public safety, to pilot-test clinical consults via telemedicine in a medically underserved area. We describe the methods, outcomes, and implications for practice.

Unpacking determinants and consequences of food insecurity for insulin resistance among people living with HIV: Conceptual framework and protocol for the NOURISH-OK study.

Background: Over the past four decades, advances in HIV treatment have contributed to a longer life expectancy for people living with HIV (PLWH). With these gains, the prevention and management of chronic co-morbidities, such as diabetes, are now central medical care goals for this population. In the United States, food insecurity disproportionately impacts PLWH and may play a role in the development of insulin resistance through direct and indirect pathways. The Nutrition to Optimize, Understand, and Restore Insulin Sensitivity in HIV for Oklahoma (NOURISH-OK) will use a novel, multi-level, integrated framework to explore how food insecurity contributes to insulin resistance among PLWH. Specifically, it will explore how food insecurity may operate as an intermediary risk factor for insulin resistance, including potential linkages between upstream determinants of health and downstream consequences of poor diet, other behavioral risk factors, and chronic inflammation. Methods/design: This paper summarizes the protocol for the first aim of the NOURISH-OK study, which involves purposeful cross-sectional sampling of PLWH (n=500) across four levels of food insecurity to test our conceptual framework. Developed in collaboration with community stakeholders, this initial phase involves the collection of anthropometrics, fasting blood samples, non-blood biomarkers, 24-hour food recall to estimate the Dietary Inflammatory Index (DII®) score, and survey data. A 1-month, prospective observational sub-study (total n=100; n=25 for each food security group) involves weekly 24-hour food recalls and stool samples to identify temporal associations between food insecurity, diet, and gut microbiome composition. Using structural equation modeling, we will explore how upstream risk factors, including early life events, current discrimination, and community food access, may influence food insecurity and its potential downstream impacts, including diet, other lifestyle risk behaviors, and chronic inflammation, with insulin resistance as the ultimate outcome variable. Findings from these analyses of observational data will inform the subsequent study aims, which involve qualitative exploration of significant pathways, followed by development and testing of a low-DII® food as medicine intervention to reverse insulin resistance among PLWH (ClinicalTrials.gov Identifier: NCT05208671). Discussion: The NOURISH-OK study will address important research gaps to inform the development of food as medicine interventions to support healthy aging for PLWH.

US trends in mask wearing during the COVID-19 pandemic depend on rurality.

INTRODUCTION: Face masks are widely recommended as a COVID-19 prevention strategy. State mask mandates have generally reduced the spread of the disease, but decisions to wear a mask depend on many factors. Recent increases in case rates in rural areas following initial outbreaks in more densely populated areas highlight the need to focus on prevention and education. Messaging about disease risk has faced challenges in rural areas in the past. While surges in cases within some communities are likely an impetus for behavior change, rising case rates likely explain only part of mask-wearing decisions. The current study examined the relationship between county-level indicators of rurality and mask wearing in the USA. METHODS: National data from the New York Times' COVID-19 cross-sectional mask survey was used to identify the percentage of a county's residents who reported always/frequently wearing a mask (2-14 July 2020). The New York Times' COVID-19 data repository was used to calculate county-level daily case rates for the 2 weeks preceding the mask survey (15 June - 1 July 2020), and defined county rurality using the Index of Relative Rurality (n=3103 counties). Multivariate linear regression was used to predict mask wearing across levels of rurality. The model was adjusted for daily case rates and other relevant county-level confounders, including county-level indicators of age, race/ethnicity, gender, political partisanship, income inequality, and whether each county was subject to a statewide mask mandate. RESULTS: Large clusters of counties with high rurality and low mask wearing were observed in the Midwest, upper Midwest, and mountainous West. Holding daily case rates and other county characteristics constant, the predicted probability of wearing a mask decreased significantly as counties became more rural (β=-0.560; p<0.0001). CONCLUSION: Upticks in COVID-19 cases and deaths in rural areas are expected to continue, and localized outbreaks will likely occur indefinitely. The present findings highlight the need to better understand the mechanisms underlying perceptions of COVID-19 risk in rural areas. Dissemination of scientifically correct and consistent information is critical during national emergencies.

An analysis of research quality underlying IDSA clinical practice guidelines: a cross-sectional study.

Context: As a result of new developments in medicine, the need for evidence-based clinical practice guidelines (CPG) is of utmost importance. However, studies have shown that many medical societies are using low quality research to develop CPGs. Objectives: To evaluate the quality of research underlying the CPGs issued by the Infectious Diseases Society of America (IDSA). Methods: We examined 29 CPGs issued between January 1, 2012 and December 31, 2019 and classified each by research quality according to levels reported by the CPG authors and previously specified by the IDSA: Levels I through III, corresponding to high, moderate, and low quality of evidence, respectively. Each ranking was cross-checked with a second researcher to improve inter-rater reliability. To analyze evolution of research quality over time, three updated CPGs were randomly selected and compared to their original versions. Chi-square analysis was then performed to determine statistical significance. Results: We evaluated the quality of research for 2,920 recommendations within the 29 CPGs that met our criteria and found that 418 (14%) were developed using high-quality (Level I) research from randomized, controlled trials. Of the remaining recommendations, 928 (32%) were based on moderate quality research (observational studies) and 1574 (54%) on low quality research (expert opinion). A Pearson chi-squared analysis indicated no-statistically significant difference between original guidelines or their subsequent updates for Clostridium difficile (χ2=0.323; n=85; degrees of freedom [df]=2; p=0.851), candidiasis (χ2=4.133; n=195; df=2; p=0.127), or coccidiomycosis (χ2=0.531; n=95; df=1; p=0.466). Conclusions: The proportion of high-quality research underlying guideline recommendations is remarkably low, indicating that moderate and low quality evidence is still influencing infectious disease guidelines despite IDSA standards. Moreover, the quality of research has not significantly changed over time. IDSA CPGs are a formidable source of information for clinicians, but an increased number of quality studies should be utilized to further guide CPG development.

Adverse Childhood Events in American Indian/Alaska Native Populations.

INTRODUCTION: Adverse childhood experiences are linked to deleterious outcomes in adulthood. Certain populations have been shown to be more vulnerable to adversity in childhood than others. Despite these findings, research in this area lacks an empirical investigation that examines adverse childhood experiences among American Indian and Alaska Native populations using large, nationally representative data. As such, the authors have compiled what they believe is the largest empirical investigation of adverse childhood experiences among American Indian and Alaska Native individuals to date. METHODS: Data were collected from the Behavioral Risk Factor Surveillance System from 34 states (2009-2017), whereby all individuals self-report as American Indian and Alaska Native (N=3,894). Adverse childhood experience scores were calculated and further stratified by sex, age, household income, education, employment status, sexual orientation, Census region, and state. In addition, frequencies and prevalence of each adverse childhood experience domain (stratified by the same categories) were calculated. Analysis was conducted in 2019. RESULTS: The average adverse childhood experience score among American Indians and Alaska Natives was 2.32, higher than those of individuals identifying as White (1.53), Black (1.66), and Hispanic (1.63). Female participants had a higher average adverse childhood experience score than male participants (2.52 vs 2.12). Generally, younger individuals and those with lower incomes reported higher adverse childhood experience scores, whereas those with higher educational attainment reported lower scores. CONCLUSIONS: Compared with the few studies among American Indian and Alaska Native populations that have used either smaller samples or nontraditional adverse childhood experience data (i.e., asking parents about their children's experiences), these results present overall higher adverse childhood experience averages than previously published studies. Nevertheless, aligning with other research on adverse childhood experiences, female individuals, younger adults, and sexual minorities reported higher adverse childhood experiences scores than other categories in their respective demographics.

Clinical trial registry searches are under-utilized in systematic reviews from critical care journals: A bibliometric analysis.

PURPOSE: Publication bias has a significant impact on the results of systematic reviews. Clinical trial registry searches, which include unpublished research, should be conducted when performing systematic reviews to reduce publication bias. We aimed to analyze the use of clinical trial registry searches in critical care systematic reviews. METHODS: Systematic reviews published between 01/01/2010-02/18/2020 from the top 5 critical care journals were extracted from PubMed and screened for trial registry use. Additionally, of the studies not performing registry searches, we assessed ClinicalTrials.gov for potentially relevant trials that were missed by not performing a registry search. RESULTS: Three hundred and twenty six systematic reviews were analyzed, of which 37 (11.3%) performed trial registry searches. Of the studies not performing clinical trial registry searches, 56% had at least 1 potentially relevant trial that was missed. CONCLUSIONS: The omission of relevant, unpublished clinical trial results may be negatively impacting the accuracy of critical care systematic reviews. We recommend all systematic reviewers conduct clinical trial registry searches to reduce publication bias.

The Role of State Medicaid Expansions in Integrating Comprehensive Mental Health Services into Opioid Treatment Programs: Differences Across the Rural/Urban Continuum.

Co-occurring mental health (MH) problems are common among those with opioid use disorders (OUDs). However, most opioid treatment programs (OTPs) do not provide MH services. We measured the association between state level characteristics (Medicaid expansion status and rurality) and MH/OUD services integration. We used a generalized linear model to estimate how the association between integration and Medicaid expansions varied across levels of rurality (National Survey on Substance Abuse Treatment Services; 2018; n = 1507 OTPs). The predicted probability of OTPs offering MH services decreased as rurality increased, and the strength of the negative association was greater in non-expansion states ([Formula: see text]=-0.038, SE = 0.005, p < 0.0001) than in expansion states ([Formula: see text]=-0.020, SE = 0.003, p < 0.0001). Access to integrated MH services was lowest in rural non-Medicaid expansion states, despite the high risk of opioid misuse and a high need for MAT and MH services in this population.

The frequencies and disparities of adverse childhood experiences in the U.S.

BACKGROUND: Adversity experienced during childhood manifests deleteriously across the lifespan. This study provides updated frequency estimates of ACEs using the most comprehensive and geographically diverse sample to date. METHODS: ACEs data were collected via BRFSS (Behavioral Risk Factor Surveillance System). Data from a total of 211,376 adults across 34 states were analyzed. The ACEs survey is comprised of 8 domains: physical/emotional/sexual abuse, household mental illness, household substance use, household domestic violence, incarcerated household member, and parental separation/divorce. Frequencies were calculated for each domain and summed to derive mean ACE scores. Findings were weighted and stratified by demographic variables. Group differences were assessed by post-estimation F-tests. RESULTS: Most individuals experienced at least one ACE (57.8%) with 21.5% experiencing 3+ ACEs. F-tests showed females had significantly higher ACEs than males (1.64 to 1.46). Multiracial individuals had a significantly higher ACEs (2.39) than all other races/ethnicities, while White individuals had significantly lower mean ACE scores (1.53) than Black (1.66) or Hispanic (1.63) individuals. The 25-to-34 age group had a significantly higher mean ACE score than any other group (1.98). Generally, those with higher income/educational attainment had lower mean ACE scores than those with lower income/educational attainment. Sexual minority individuals had higher ACEs than straight individuals, with significantly higher ACEs in bisexual individuals (3.01). CONCLUSION: Findings highlight that childhood adversity is common across sociodemographic, yet higher in certain categories. Identifying at-risk populations for higher ACEs is essential to improving the health outcomes and attainment across the lifespan.

Assessing the Health Care Experiences of Rural Men Who Have Sex with Men (MSM).

Research investigating the health care experiences of men who have sex with men (MSM) predominately concerns urban populations. This study examines the health care experiences of MSM residing in rural Oklahoma. A total of 40 MSM (aged 21 through 66) living in rural areas were interviewed. Data were analyzed using a qualitative approach to identify emerging concepts. Three themes emerged from the data: First, participants cited cultural differences related to religious conservative ideologies as a central motif of health care experiences. Next, doctor-patient relationship quality was a contributing factor to health care experiences. Last, health care experiences were predicated on the idea of doctors' knowledge of lesbian, gay, bisexual and transgender (LGBT) health issues. Certain health care aspects regarding the rural experiences of MSM that were identified differed between rural and urban MSM. Implications include support for programs that bridge the gap between practitioners and patients, while better informing both MSM and health care providers of current LGBT health issues.

Factors Associated with Condom Use among a Sample of Men Who Have Sex with Men (MSM) Residing in Rural Oklahoma.

Public health literature often neglects populations from rural communities, particularly with men who have sex with men (MSM). Although HIV/STI infections are decreasing slightly, there is an increase within rural MSM, thus opening the door for further research on condom use behavior in a rural context. In-depth interviews were conducted with 40 MSM in rural Oklahoma regarding their condom use and sexual behaviors. A qualitative analysis revealed five themes with respect to condom usage: physical discomfort of condoms, relationship trust, usage based on the type of sexual act, substance use, and knowledge of a partner's HIV/STI status. A sixth theme within the context of rural Oklahoma revealed participants' fear of physical/verbal abuse, hesitations seeking medical help due to confidentially issues, and general acknowledgment of the lack of education and resources available. Implications include increasing mobile testing locations and a push for marketing greater confidentially within health service providers.

Experiences of Stigma by Gay and Bisexual Men in Rural Oklahoma.

Purpose: The unique experiences of men who have sex with men (MSM) residing in culturally conservative rural areas are not well represented in the scientific literature. The human immunodeficiency virus (HIV) epidemic in the United States has shifted toward rural areas where populations are dispersed and health care resources are limited. Methods: We recruited 40 sexual minority men, ages 22-66, residing in rural Oklahoma for in-depth, qualitative sexual health interviews that sought to understand how cultural and social environments impacted health behaviors. Findings: Participants described a stigmatizing social environment and less access to quality, sexual minority medical care within rural communities and perceived these as substantial barriers to enhancing health. Structural issues, including lack of sexual minority-affirming policies, institutional practices, and hostile cultural norms, were noted. Conclusions: Results indicate the need to develop greater awareness of stigma as an etiologic factor that contributes to the health of rural sexual minority populations, specifically when it relates to provision of culturally appropriate care.

Using Structural Equation Modeling to Examine the Influence of Social, Behavioral, and Nutritional Variables on Health Outcomes Based on NHANES Data: Addressing Complex Design, Nonnormally Distributed Variables, and Missing Information.

BACKGROUND: Structural equation modeling (SEM) is a multivariate analysis method for exploring relations between latent constructs and measured variables. As a theory-guided approach, SEM estimates directional pathways in complex models based on longitudinal or cross-sectional data where randomized control trials would either be unethical or cost prohibitive. However, this method is infrequently used in nutrition research, despite recommendations by epidemiologists for its increased use. OBJECTIVES: The aim of this study was to explore 3 key methodologic areas for consideration by researchers when conducting SEM with complex survey datasets: the use of sampling weights, treatment of missing data, and model estimation techniques. METHODS: With the use of data from NHANES waves 2005-2010, we developed an SEM to estimate the relation between the latent construct of depression and measured variables of food security, tobacco use (serum cotinine), and age. We used a hierarchic approach to compare 5 SEM model iterations through the use of: 1 and 2) complete cases without and with the application of sampling weights; 3) an applied missingness dataset to test the accuracy of multiple imputation (MI); 4) the full NHANES dataset with imputed data and sampling weights; and 5) a final respecified model. Each iteration was conducted with maximum likelihood (ML) and quasimaximum likelihood with the Satorra-Bentler correction (QML) to compare path coefficients, standard errors, and model fit statistics. RESULTS: Path coefficients differed between 15.68% and 19.17% among model iterations. Nearly one-third of the cases had missing values, and MI reliably imputed values, allowing all cases to be represented in the final model iterations. QML provided better model fit statistics in all iterations. CONCLUSIONS: Nutrition epidemiologists should use complex weights, MI, and QML as a best-practices approach to SEM when conducting analyses with complex design survey data.

Adverse childhood experiences and MSM marijuana use.

BACKGROUND: Past research identified individuals who experienced adverse childhood experiences (ACEs) are at a higher risk of drug use. There is evidence to suggest that identifying as a man who has sex with other men (MSM) may increase the likelihood of drug use when adverse childhood experiences are prevalent. However, research has not addressed if this association is present in both rural and urban MSM, as other studies found that rurality/urbanity is a key determinant in detrimental outcomes for MSM. The current study uses ACEs as an independent variable in comparing rural and urban MSM's self-reported marijuana use. METHODS: Participants included 156 MSM residing in Oklahoma. Linear regression was used to test ACEs' associations with reported marijuana use. To explore nuanced differences between rural and urban populations, split sample regressions were conducted. RESULTS: ACEs were statistically associated with reported marijuana use in the full sample. However, after splitting the sample, ACEs only predicted reported marijuana use in the urban and not in the rural sample. CONCLUSIONS: Results suggest ACEs may affect rural and urban MSM dissimilarly. It is unclear, however, if rural MSM engage in maladaptive behaviors other than marijuana use, or if factors associated with urban environments make urban MSM more vulnerable to illicit drug use when ACEs are high. Regardless, trauma informed programming targeting MSM should consider geographic locale as an influential factor. Further investigation is needed with regards to geographic locale, ACEs, and other illicit drug use in MSM populations.

Prior Knowledge of the Mediterranean Diet Is Associated With Dietary Adherence in Cardiac Patients.

CONTEXT: Cardiovascular disease (CVD) is the leading cause of death in the United States, and cardiovascular events have been shown to be reduced and prevented when patients follow the Mediterranean diet. OBJECTIVE: To understand how familiarity with the Mediterranean diet affects dietary habits in cardiology patients by using social cognitive theory. METHOD: This cross-sectional study included patients at a metropolitan outpatient cardiology clinic in Oklahoma. A survey was used to analyze patient knowledge of the Mediterranean diet. Patients were separated into low-, medium-, and high-diet adherence groups based on their daily consumption of fruits, vegetables, fish, whole grains, and nuts. Multinomial logistic regression was used to analyze patients' knowledge of Mediterranean diet principles with dietary adherence. RESULTS: A total of 337 patients were included in the study. Patients with a college education, patients reporting familiarity with the diet, and women were 6.7, 4.0, and 3.2 times as likely, respectively, to have strong adherence to the Mediterranean diet. CONCLUSION: The finding that familiarity with the Mediterranean diet was closely associated with adherence to its principles indicates that patient education on heart-healthy diets may improve the eating habits of patients, especially patients at risk for cardiac events.

Mediterranean Diet Adherence in Cardiac Patients: A Cross-sectional Study.

Objective We analyzed the constructs of social cognitive theory that explain adherence to the Mediterranean diet in patients diagnosed with cardiovascular disease. Methods A cross-sectional study of 337 cardiac patients using a validated questionnaire was conducted and analyzed at an outpatient cardiology clinic, employing social cognitive theory (SCT) as the theoretical framework. Results Dietary adherence was associated with statistically significant improvements in the SCT constructs. Self-regulation to consume healthy diet groups, negative perceived outcomes, and self-efficacy had the most influence on patient ability to maintain the Mediterranean diet. Self-regulation to avoid unhealthy food options like processed, sugary foods and positive perceived outcomes had smaller associations with patient ability to maintain the Mediterranean diet. Conclusions SCT constructs should be utilized by physicians when educating patients on heart healthy dieting as they are highly associated with improved dietary behaviors. Self-efficacy, self-regulation in choosing healthy diet options, and negatively perceived expected outcomes predicted diet quality in cardiac patients. Improvements in these constructs might yield positive results in cardiac patients attempting diet modifications.

Barriers to Access and Adoption of Pre-Exposure Prophylaxis for the Prevention of HIV Among Men Who Have Sex With Men (MSM) in a Relatively Rural State.

Biomedical intervention approaches, including antiretroviral pre-exposure prophylaxis (PrEP), have been demonstrated to reduce HIV incidence among several at-risk populations and to be cost effective. However, there is limited understanding of PrEP access and uptake among men who have sex with men (MSM) residing in relatively rural states. Twenty semistructured interviews were conducted (August-November 2016) to assess opinions of and perceived barriers to accessing and adopting PrEP among MSM residing in Oklahoma. Participants perceived substantial barriers to accessing PrEP including a stigmatizing environment and less access to quality, LGBT-sensitive medical care. Overall, geographic isolation limits access to health providers and resources that support sexual health for Oklahoma MSM. Addressing stigma situated across ecological levels in an effort to increase adoption of PrEP by MSM residing in rural states remains necessary. Without this, social determinants may continue to negatively influence PrEP adoption and sexual health outcomes.

Preparing Physicians for Rural-Based Primary Care Practice: A Preliminary Evaluation of Rural Training Initiatives at OSU-COM.

The physician shortage in Oklahoma coupled with geographic maldistribution of primary care physicians limits access to care in rural and underserved areas. One of the most effective strategies to recruit and retain physicians in rural areas is to create undergraduate and graduate medical education training sites in these locations. Oklahoma State University Center for Health Sciences College of Osteopathic Medicine has implemented a rural training program that begins with early recruitment of rural high school students, introduces medical students to rural practice options through rural clinical training opportunities, and provides opportunities to remain in rural Oklahoma for residency training through ongoing graduate medical education development. The purpose of this article is to provide a case study of the development of the college's Rural Medical Track. Preliminary findings indicate that rural-based clinical training for third- and fourth-year students strengthens performance on standardized tests.

What Can the National Broadband Map Tell Us About the Health Care Connectivity Gap?

PURPOSE: Internet connection speeds are generally slower in rural areas, and this issue is rising in importance for health care facilities as technologies such as Electronic Health Records and Health Information Exchanges become more common. However, the extent of the rural-urban divide in terms of health care connectivity has not been fully quantified. This report uses data compiled from the National Broadband Map (NBM) to compare levels of health care facility connectivity across metropolitan and nonmetropolitan counties. METHODS: The number of health and medical entries in the Community Anchor Institution (CAI) data collected as part of the NBM grew from 35,000 to 63,000 between 2010 and 2014. About one-fifth provided information on the speed of their connections in 2014. Comparisons across metro and nonmetro counties and over time provide insight into trends associated with the health care connectivity gap. FINDINGS: The data clearly show that health-related institutions in nonmetro counties connect with lower speeds than do their more urban counterparts. At the aggregate level, over 55% of metro institutions who provided speed information had download speeds in excess of 50 megabytes per second in 2014, compared with only 12% of nonmetro institutions (P < .001). More importantly, the connectivity gap has grown significantly during 2010-2014, particularly for nonhospital facilities. CONCLUSIONS: The NBM CAI data are a publicly available and easy to use asset that rural health advocates should be aware of. The fact that the connectivity gap increased during 2010-2014, despite policies focusing on this issue, is a cause for concern.