A Persistent Disparity: Smoking in Rural Sexual and Gender Minorities.

PURPOSE: Sexual and gender minorities (SGM) smoke cigarettes at higher rates than the general population. Historically, research in SGM health issues was conducted in urban populations and recent population-based studies seldom have sufficient SGM participants to distinguish urban from rural. Given that rural populations also tend to have a smoking disparity, and that many SGM live in rural areas, it is vitally important to understand the intersection of rural residence, SGM identity, and smoking. This study analyzes the patterns of smoking in urban and rural SGM in a large sample. METHODS: We conducted an analysis of 4280 adult participants in the Out, Proud, and Healthy project with complete data on SGM status, smoking status, and zip code. Surveys were conducted at 6 Missouri Pride Festivals and online in 2012. Analysis involved descriptive and bivariate methods, and multivariable logistic regression. We used GIS mapping to demonstrate the dispersion of rural SGM participants. RESULTS: SGM had higher smoking proportion than the non-SGM recruited from these settings. In the multivariable model, SGM identity conferred 1.35 times the odds of being a current smoker when controlled for covariates. Rural residence was not independently significant, demonstrating the persistence of the smoking disparity in rural SGM. Mapping revealed widespread distribution of SGM in rural areas. CONCLUSION: The SGM smoking disparity persists among rural SGM. These communities would benefit from continued research into interventions targeting both SGM and rural tobacco control measures. Recruitment at Pride Festivals may provide a venue for reaching rural SGM for intervention.

Electronic Cigarette Retail Outlets and Proximity to Schools.

PURPOSE: To compare the retail distribution and density per population of electronic and conventional cigarettes in smoke-free communities with and without e-cigarette restrictions. DESIGN: A cross-sectional study with field observations of retail tobacco stores. SETTING: Two Central Kentucky counties with 100% smoke-free workplace regulations; counties selected on the basis of whether e-cigarette use was restricted. SUBJECTS: Fifty-seven tobacco retailers in two counties, including conventional retailers and stand-alone e-cigarette stores. MEASURES: Type and location of store and products sold; addresses of stores and schools geocoded with ArcGIS. ANALYSIS: Bivariate comparisons between counties, rates and confidence intervals for frequency of tobacco retailers and e-cigarette stores per population. RESULTS: Fifty-three percent of tobacco retailers sold e-cigarettes. E-cigarette availability did not differ by whether smoke-free regulation covered e-cigarettes. Rates of tobacco retailers and e-cigarette distributors per 10,000 were 8.29 and 4.40, respectively, in the two-county area. Of the 40 schools, 88% had a tobacco retailer and 68% had an e-cigarette distributor within 1 mile. CONCLUSION: In this exploratory study, e-cigarette use restriction was not related to store availability. For a relatively new product, e-cigarettes were readily available in retail outlets and close to schools.

Achieving meaningful use of electronic health records (EHRs) in primary care: Proposed critical processes from the Kentucky Ambulatory Network (KAN).

OBJECTIVE: The Kentucky Ambulatory Network, a practice-based research network, conducted this study to propose critical processes for electronic health record (EHR) implementation. METHODS: Periodic observation of the implementation process and assessment of meaningful use (MU) metrics within 10 small primary care practices working with a regional extension center. RESULTS: Through focus groups and structured interviews, the strategies, processes, and procedures used by these practices to achieve MU of EHRs were determined. Implementation themes related to and critical processes associated with EHR adoption were proposed. CONCLUSIONS: Five proposed critical processes for EHR adoption and achievement of MU were identified; these processes were supported by 70% (7 of 10) of the study practices meeting MU criteria.

Geomapping telehealth access to developmental-behavioral pediatrics.

BACKGROUND: Geographic information systems (GIS) mapping is fairly novel in describing utilization of health services. Our study is the first to use GIS to demonstrate that telehealth pediatric specialty service access would create substantial savings in travel time and distance compared with accessing a tertiary-care center for similar service. MATERIALS AND METHODS: A retrospective chart review of telehealth encounters and geocoding of patients' address were done with actual travel along road calculations to estimate travel time and distance for a visit, compared with a hypothetical visit to the nearest tertiary-care site for the similar service. RESULTS: Over a 2-year period, 255 telehealth visits by 171 patients with a variety of developmental and behavioral diagnoses were made to five telehealth sites. The median travel time and distance saved by accessing a telehealth site were 66.9 min and 63.8 miles, respectively. Of these patients, 12.3% had a median negative estimated savings of 52.7 min and 39.0 miles, which was associated with longer travel burden. Using the straight-line method underestimated the total time and distance traveled by approximately one-quarter of the actual distance (median distance of 20.5 miles underestimate relative to the median distance of 100.7 miles). CONCLUSIONS: Telehealth patients experienced significant reduction in travel times and distances. Patients/families would accept an increased burden of spatial accessibility in exchange for reduced burdens in other aspects of access, such as accommodation or acceptability when engaging telehealth services. Using a road network-based method is more accurate than previously used straight-line methods in calculating distance impedance.

An intervention to increase compliance with a tobacco-free university policy.

PURPOSE: To test the effects of a population-based self-efficacy message card campaign on compliance with a tobacco-free campus policy. SETTING: This study was conducted at a large public university in the South. SUBJECTS: Three hundred twelve observational periods at 39 campus sites. INTERVENTION: The message card campaign, based on the Theory of Planned Behavior, consisted of distributing approximately 6000 efficacy-enhancing cards over 3 days. The intent of the cards was to increase awareness of the policy and resources available to help individuals stop smoking or remain comfortable while on campus. MEASURES: Policy compliance was measured using the Tobacco-Free Compliance Assessment Tool. Field notes were used to assess campaign reaction. ANALYSIS: Mann-Whitney U-test was conducted to compare number of cigarette butts in hot spot areas before and after the intervention. A rate ratio was also calculated using Geographic Information System (GIS) mapping software to compare cigarette butts collected per day before and after the intervention at each of the study sites. RESULTS: The median number of cigarette butts per day after the intervention was significantly lower than before the intervention (1.9 vs. 4.7, χ(2): 8.1, p  =  .004). Eighteen sites (66.6%) had a post-pre ratio of .11 to .75, indicating a decrease in cigarette butts per day. CONCLUSION: An efficacy-enhancing message card campaign shows promise in improving compliance with tobacco-free campus policies.

Measuring compliance with tobacco-free campus policy.

OBJECTIVE: The purpose is to describe psychometric testing and feasibility of the Tobacco-Free Compliance Assessment Tool (TF-CAT) to measure tobacco-free policy compliance at a public university and medical center. The aims are to (1) investigate concurrent validity by comparing the number of cigarette butts in areas covered by the policy with those on adjacent sidewalks; (2) evaluate the interrater reliability of the TF-CAT; and (3) describe the feasibility of using the TF-CAT. METHODS: Phase I was a pilot study on the health care campus. Phase II was baseline of an intervention study on the main campus. Cigarette butts and smokers were counted in hot spots. Validity was assessed using Mann-Whitney U and Geographical Information System Analysis methods. RESULTS: There was some support for the validity and high interrater reliability. Data collectors spent 1 hour per week for 8 weeks during Phase I, and 31 hours in 1 week during Phase II. CONCLUSION: TF-CAT is a feasible, time-intensive method to measure tobacco-free policy compliance.

The dental workforce in Kentucky: current status and future needs.

OBJECTIVES: This study assessed the geographic distribution of dentists in Kentucky, determined socioeconomic correlates of practice location, estimated the future availability of dental providers, and made policy recommendations that could improve access to oral health care in Kentucky and other rural states. METHODS: Dentists' addresses were mapped using a geographic information system. Poisson regression modeling and geospatial analyses were conducted using SAS v9.1 (SAS Institute, Cary, NC, USA) and ArcGIS v9.2 (Environmental Systems Research Institute Inc., Redlands, CA, USA), respectively. Data on the number of dentists (n = 2,391) per county (n = 120) were used for the regression models. Explanatory variables included: per capita income, 2006 intercensal population estimates, percent adults with six or more teeth removed, percent population uninsured, physician-to-population ratios, and region type. A simulation model was used to project dentist-to-population ratios to the year 2016. RESULTS: The dental workforce analysis revealed disparities in the distribution of dentists between rural, urban, and Appalachian Kentucky counties. Dentists were more likely to be found practicing in areas with higher income and higher physician-to-population ratios. Compounding this geographic maldistribution, our projections suggest that the number of dentists per unit population will decrease over time in the near future, likely widening this disparity in rural and underserved areas. CONCLUSIONS: These results show present and widening workforce disparities in rural and socioeconomically depressed counties in Kentucky. Understanding the geographic distribution of dentists and the socioeconomic correlates of their practice locations may inform workforce development and reimbursement policies for the goal of improving access to oral health care in these areas.

Increasing the medical school applicant pool: a key to training more rural physicians.

CONTEXT: Workforce studies show shortages of physicians in many areas of the United States. These shortages are especially severe in states such as Kentucky with many rural counties and are predicted to worsen in the future unless there are changes throughout our educational system to build aspirations and prepare students for medical school education. PURPOSE: To examine rural-urban differences and community characteristics of applicants and matriculants to Kentucky's two allopathic medical schools and influences on the educational aspirations of young students who wish to become physicians. METHODS: The number of Kentucky applicants and matriculants to allopathic medical schools was obtained from the Association of American Medical College's data warehouse for the period from 2002-2006. A continuous, multidimensional measure was used to classify counties by degree of rurality. Socio-demographic variables were selected for the counties of residence for applicants and matriculants. Model variables were tested in a least squares multiple regression model for their ability to explain patterns among Kentucky's 120 counties in the number of both resident applicants and matriculants to medical school. Data from a survey of middle school participants in summer health camps were analyzed to help identify important influences on young students aspiring to a career as a health professional, especially becoming a physician, and how these might be supported to increase the supply of rural medical school applicants. FINDINGS: The low number of rural applicants to medical school was highly correlated with the relative rurality of their county of residence, a low physician-to-population ratio and a low number of total primary care physicians. The percentage of county residents having a bachelor's degree level of education or higher had a positive impact on the application rate. Respondents became interested in health careers at age 15 or younger, and parents and grandparents, teachers, and close associates stimulated their aspirations, with teachers being the most influential. CONCLUSIONS: Prospective students respond to their perception of need for physicians. Rural students are influenced by those who are more highly educated. To overcome the shortage of physicians in rural communities efforts must be made to increase the aspirations for medical education of prospective students from rural counties.

Violence and drug use in rural teens: national prevalence estimates from the 2003 Youth Risk Behavior Survey.

OBJECTIVES: The purpose of this study was to compare national estimates of drug use and exposure to violence between rural and urban teens. METHODS: Twenty-eight dependent variables from the 2003 Youth Risk Behavior Survey were used to compare violent activities, victimization, suicidal behavior, tobacco use, alcohol use, and illegal drug use across rural, urban, and suburban teens across the country. RESULTS: Overall, rural teens were equally or more likely than both suburban and urban teens to report experiencing many measures of violent behavior, victimization, suicide behaviors, and drug use. Among all teens, nonwhites reported equal or higher rates of violent behavior and victimization than whites, but these associations disappeared within the rural-only population. CONCLUSIONS: Rural areas do not appear to provide a strongly protective effect against risk behaviors in teens and may be a risk factor in itself. Community prevention efforts should focus on reaching rural areas and segmenting program content based on need. Where white teens might benefit from an emphasis on preventing tobacco and alcohol use, nonwhite teens would benefit from an emphasis on preventing violence and victimization.

Rural hospitals and Spanish-speaking patients with limited English proficiency.

Between 1990 and 2000, the Latino population in the United States increased by 61 percent, becoming the largest minority group. Language differences contribute to patient safety and access to healthcare concerns for limited English proficiency (LEP) Latinos. The objectives of this research were to determine the techniques rural hospitals use to accommodate Spanish-speaking LEP patients, to identify strengths and barriers to providing language services, and to describe local approaches to language assistance services. Surveys were mailed to 841 hospitals in 544 rural counties with moderate to high Latino growth rates between 1990 and 2000. A total of 319 rural hospitals responded. Nearly all rural hospitals reported having tools to help patients communicate language needs. The most commonly used tools include brochures, language identification posters, and language identification cards. Strengths were institutional support for language assistance services, staff willingness to use interpreters, and access to telephone language lines. Principal barriers included lack of funding for interpreters, lack of local language training programs, and lack of state agency support. Hospitals that serve counties with higher Latino population growth rates reported higher demand for services compared with those counties with smaller Latino population growth rates. Several innovative approaches were also identified. Various language accommodation resources, tools, and strategies are available for hospitals to help them serve LEP clientele. Hospitals should routinely review their policies and procedures for language assistance services to ensure compliance with federal and Joint Commission standards.

Effects of residence and race on burden of travel for care: cross sectional analysis of the 2001 US National Household Travel Survey.

BACKGROUND: Travel burden is a key element in conceptualizing geographic access to health care. Prior research has shown that both rural and minority populations bear disproportionate travel burdens. However, many studies are limited to specific types of patient or specific locales. The purpose of our study was to quantify geographic and race-based differences in distance traveled and time spent in travel for medical/dental care using representative national data. METHODS: Data were drawn from 2001 National Household Travel Survey (NHTS), a nationally representative, cross-sectional household survey conducted by the US Department of Transportation. Participants recorded all travel on a designated day; the overall response rate was 41%. Analyses were restricted to households reporting at least one trip for medical and/or dental care; 3,914 trips made by 2,432 households. Dependent variables in the analysis were road miles traveled, minutes spent traveling, and high travel burden, defined as more than 30 miles or 30 minutes per trip. Independent variables of interest were rural residence and race. Characteristics of the individual, the trip, and the community were controlled in multivariate analyses. RESULTS: The average trip for care in the US in 2001 entailed 10.2 road miles (16.4 kilometers) and 22.0 minutes of travel. Rural residents traveled further than urban residents in unadjusted analysis (17.5 versus 8.3 miles; 28.2 versus 13.4 km). Rural trips took 31.4% longer than urban trips (27.2 versus 20.7 minutes). Distance traveled did not vary by race. African Americans spent more time in travel than whites (29.1 versus 20.6 minutes); other minorities did not differ. In adjusted analyses, rural residence (odds ratio, OR, 2.67, 95% confidence interval, CI 1.39 5.1.5) was associated with a trip of 30 road miles or more; rural residence (OR, 1.80, CI 1.09 2.99) and African American race/ethnicity (OR 3.04. 95% CI 2.0 4.62) were associated with a trip lasting 30 minutes or longer. CONCLUSION: Rural residents and African Americans experience higher travel burdens than urban residents or whites when seeking medical/dental care.