Development of the Rural Active Living Perceived Environmental Support Scale (RALPESS).

BACKGROUND: Evidence supports the role of physical and social environments in active living, including perception of environment. However, measurement of perceived environments in rural settings is lacking. This study describes the development of the Rural Active Living Perceived Environmental Support Scale (RALPESS). METHODS: Premised on social ecological and cognitive perspectives, 85 initial items were generated through a literature review and a mixed-methods investigation of "activity-friendly" environments. Items were organized by resource areas--town center, indoor and outdoor physical activity areas, schools, churches, and areas around the home/neighborhood--and submitted for expert panel review. In 2009, a revised questionnaire was disseminated to adolescents, parents, public school staff, and older adults in 2 rural southeastern United States counties. Principal component analysis with varimax rotation was used to explore factor structure (n = 542). RESULTS: The final analysis yielded 33 items with 7 factors: 1) church facilities, 2) town center connectivity, 3) indoor areas, 4) around the home/neighborhood, 5) town center physical activity resources, 6) school grounds, and 7) outdoor areas. CONCLUSIONS: The RALPESS is a valid, internally consistent, and practically useful instrument to measure perceptions of rural environments in the context of physical activity across the lifespan. Confirmatory factor analysis is recommended to validate factor structure.

Understanding the rural food environment--perspectives of low-income parents.

INTRODUCTION: Childhood obesity rates appear to be more pronounced among youth in rural areas of the USA. The availability of retail food outlets in rural communities that sell quality, affordable, nutritious foods may be an important factor for encouraging rural families to select a healthy diet and potentially reduce obesity rates. Researchers use the term 'food desert' to describe communities where access to healthy and affordable food is limited. Understanding the ways in which the food environment and food deserts impact childhood obesity may be a key component to designing interventions that increase the availability of healthy and affordable foods, thus improving the health of rural communities. METHODS: The food environment was investigated in 6 rural low-income Maine communities to assess how food environments affect eating behaviors and obesity rates of rural children enrolled in Medicaid/State Children's Health Insurance Program in Maine ('MaineCare'). Focus groups were conducted with low-income parents of children enrolled in MaineCare to ask them about their food shopping habits, barriers faced when trying to obtain food, where they get their food, and what they perceive as healthy food. RESULTS: Cost, travel distance, and food quality were all factors that emerged as influential in rural low-income family's efforts to get food. Parents described patterns of thoughtful and creative shopping habits that involve coupons and sales. Grocery shopping is often supplemented with food that is harvested, hunted, and bartered. The use of large freezers for storing bulk items was reported as necessary for survival in 'tough' times. Families often travel up to 128.8 km (80 miles) to purchase good quality, affordable food, recognizing that in rural communities travelling these distances is a reality of rural life. Parents appeared to know what qualities describe 'healthy food'. CONCLUSIONS: Rural families may have greater flexibility and opportunity to be methodical in their food shopping than urban families since many have access to cars and large freezers. This creates a buffer around these rural communities that might otherwise be considered food deserts. Although the meaning of food desert may be different in rural areas than in urban, it does not negate the fact that low-income rural families are struggling. The combination of challenges that rural low-income families face call for more rigorous study to identify promising interventions for increasing food access and quality in these communities. Participants have developed creative skills for getting food on the table and they know what healthy food is. Despite having acquired this knowledge and these skills, rural families are struggling. With these struggles in mind, policy-makers should consider the shopping patterns reported in this study when thinking about how to help rural residents better access affordable, healthy and quality foods. Customary approaches to remedying the problem of food deserts in urban areas, such as building more grocery stores, may not be necessary in rural areas. More creative approaches for food-access policy changes, subsidies and incentives are needed to match the complex and multi-faceted strategies that low-income residents utilize to feed their families.

Characteristics of inpatient psychiatric units in small rural hospitals.

OBJECTIVES: This study investigated inpatient psychiatric units in small rural hospitals to determine their characteristics, the availability of community-based services after discharge, and the impact of the new Medicare payment system on these units. METHODS: Unit managers in all rural hospitals with fewer than 50 beds that had a psychiatric unit in 2006 (N=74) were surveyed on the telephone. RESULTS: On average these units had ten beds and 230 admissions per year. Medicare was the major payer (median of 84%). Typical staffing includes no more than one staff member from each category: psychiatrist, psychologist, social worker, counselor or therapist, and nurse practitioner. Common diagnoses reported were depression (74% of units), schizophrenia or other psychoses (42% of units), and dementia or Alzheimer's disease (57% of units). CONCLUSIONS: Hospital staff reported little difficulty obtaining postdischarge care, and most staff clinicians provided outpatient services locally. Thus mental health services infrastructure appears better in these communities than in most rural communities, but it may be weakened by recent closures reported by some units, caused, in part, by changes in Medicare reimbursement.

Development of the Rural Active Living Assessment Tools: measuring rural environments.

OBJECTIVE: Develop rural-specific assessment tools to be used by researchers and practitioners to measure the activity-friendliness of rural communities. METHOD: The tools were created through a mixed-methods investigation into the determinants of physical activity among rural populations. This informed the development of a conceptual framework defining activity-friendly rural environments. Questions were generated to reflect applicable existing urban-based variables and rural conceptual model elements. Pilot testing was conducted in seven rural US communities during the fall of 2008. Inter-rater reliability was assessed. RESULTS: The Rural Active Living Assessment (RALA) Tools include three components: Town-Wide (18 town characteristic questions, and inventory of 15 recreational amenities), Program and Policy (20 questions), and Street Segment (28 questions). We found that the Town-wide and Program and Policy tools were feasible for community members to implement. The observed agreement and kappa statistic across all items for the Street Segment Assessment were substantial (91.9% and 0.78, respectively). CONCLUSIONS: The RALA Tools were shown to be feasible and reliability was supported. They assess features believed to be supportive of active living in rural environments, offer users a resource to assess rural environments for activity-friendliness, and may also inform the design of interventions to help rural communities become more active and healthy.

Active living for rural youth: addressing physical inactivity in rural communities.

Rural youth are at greater risk than urban youth for obesity and physical inactivity. Active living research incorporates an ecological approach to promoting physical activity (PA) by recognizing that individual behavior, social environments, physical environments, and policies contribute to behavior change. Active living research and interventions have been limited primarily to urban settings. Because rural communities have unique environmental features and sociocultural characteristics, this project combines insights from current active living models with more focused consideration of the physical and social realities of rural areas. In this study, we report on our efforts to develop, test, and refine a conceptual model describing the interaction between the individual and the environment as it enhances or thwarts active living in rural communities. Our findings revealed a host of relevant "predisposing" and "enabling" factors, including sociodemographic, environmental, policy, and programmatic elements, that extend across the four domains of active living--transportation, recreation, occupation, and household. A one-size approach to PA promotion will not fit the needs of rural youth. Given the unique challenges that rural communities face, efforts to combat childhood obesity must consider rural residents a priority population. More research, interventions, and evaluations on ways to promote rural PA are needed.

Use of critical access hospital emergency rooms by patients with mental health symptoms.

CONTEXT: National data demonstrate that mental health (MH) visits to the emergency room (ER) comprise a small, but not inconsequential, proportion of all visits; however, we lack a rural picture of this issue. PURPOSE: This study investigates the use of critical access hospital (CAH) ERs by patients with MH problems to understand the role these facilities play in rural MH needs and the challenges they face. METHODS: Primary data were collected through the combination of a telephone survey and ER visit logs. Our sampling frame was the universe of CAHs at the time the survey was fielded. KEY FINDINGS: About 43% of CAHs surveyed operate in communities with no MH services, while 9.4% of all logged visits were by patients identified as having some type of MH problem. The most common problems identified were affective disorders, substance abuse, anxiety, and psychotic disorders. Only 32% of CAHs have access to on-site detoxification and 2% have inpatient psychiatric services, meaning that patients in need of these services typically must leave their communities to gain treatment. CONCLUSIONS: The lack of community resources may impact CAHs' ability to assist patients with MH problems. Among those with a primary MH condition, 21% left the ER with no or unknown treatment, as did 51% of patients whose MH condition was secondary to their emergent problem. Patients in need of detoxification or inpatient psychiatric services often must travel over an hour to obtain these services, potentially creating significant issues for themselves and their families.

Out-of-pocket health spending and the rural underinsured.

Multiple studies have documented higher uninsurance rates among rural compared to urban residents, yet the relative adequacy of coverage among rural residents with private health insurance remains unclear. This study estimates underinsurance rates among privately insured rural residents (both adjacent and nonadjacent to urban areas) and the characteristics associated with rural underinsurance. We found that 6 percent of privately insured urban residents were underinsured; the rate increased to 10 percent for rural adjacent and 12 percent for rural nonadjacent residents. Multivariate analyses suggest that rural residents' underinsurance status is related to the design of the private plans through which they have coverage.