The Journal Of Rural Health[JOURNAL]
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200 papers
Financial resilience of rural hospitals: Prepandemic vulnerabilities and Provider Relief Funds' role during COVID-19.
Karim SA, Carroll NW, Song PH … +1 more , Atherly A
J Rural Health · 2025 Jun · PMID 40702681 · Publisher ↗
PURPOSE: Rural hospitals struggling with prepandemic financial instability faced heightened challenges during COVID-19. While Provider Relief Funds (PRFs) offered essential support, their impact varied, highlighting the...
PURPOSE: Rural hospitals struggling with prepandemic financial instability faced heightened challenges during COVID-19. While Provider Relief Funds (PRFs) offered essential support, their impact varied, highlighting the need to examine how prepandemic financial health influenced rural hospitals' financial performance during the pandemic. This study evaluates PRF's role across three hospital categories: financially strained (low operating margin), financially vulnerable (midrange operating margin), and financially strong (high operating margin). METHODS: A cohort study with a pre-post research design analyzed 2243 US rural hospitals from 2017 to 2022. The sample included short-term general acute nonfederal hospitals and Critical Access Hospitals in nonmetropolitan counties and rural tracts within metropolitan counties. Financial health was assessed using operating margin measures and total margins with and without PRF across four time periods: pre-COVID-19 (2017-2019), COVID-19 Year 1 (2020), Year 2 (2021), and Year 3 (2022). FINDINGS: Financially strained and vulnerable hospitals represented 85% of rural hospitals. Financially strained hospitals had the lowest average operating margins from patient services (-17.36%), trailing financially vulnerable (-3.09%), and financially strong (8.04%). In COVID-19 Year 1, operating margins declined across all categories. PRF increased total margins for financially strained hospitals to 8.39% in 2021 before dropping to 0.76% in 2022. Financially vulnerable hospitals also benefited, while financially strong hospitals remained profitable even without PRF. CONCLUSION: PRF played a critical role in stabilizing rural hospitals, mitigating financial declines, and preventing closures. Its expiration leaves many hospitals facing renewed financial pressures. Addressing long-term financial challenges through sustainable funding strategies and operational adaptations will be essential to preserving health care access in rural communities.
Financial performance of rural and urban nursing homes: A comparative analysis.
Orewa GN, Pradhan R, Ghiasi A … +2 more , Gupta S, Weech-Maldonado R
J Rural Health · 2025 Jun · PMID 40696838 · Full text
PURPOSE: The financial sustainability of nursing homes is increasingly critical as the aging US population continues to grow. Rural facilities often encounter more significant economic challenges than urban counterparts....
PURPOSE: The financial sustainability of nursing homes is increasingly critical as the aging US population continues to grow. Rural facilities often encounter more significant economic challenges than urban counterparts. This study investigates the disparities in financial performance between rural and urban nursing homes in the United States, emphasizing the influence of organizational and environmental factors. A comprehensive understanding of these differences is necessary for the implementation of effective policy and management interventions. METHODS: The study used a longitudinal dataset (2018-2022) comprising 66,056 nursing home-year observations. Data sources included Centers for Medicare and Medicaid Services (CMS) Cost Reports, Payroll-Based Journal, Care Compare, LTCFocus, and the Area Health Resource File. The dependent variable was the operating margin. The primary independent variable, geographic location, was classified using Rural-Urban Commuting Area (RUCA) codes. We conducted multivariable linear regression with facility-level random effects and two-way fixed effects (state and year) to assess rural-urban financial disparities while controlling for organizational and environmental factors and the impact of COVID-19. FINDINGS: Rural nursing homes had lower operating margins than urban facilities in unadjusted models. However, after adjusting for organizational factors such as size, occupancy, and payer mix, the rural-urban difference was no longer significant. Environmental factors, including population demographics and income levels, contributed to financial disparities. COVID-19 exacerbated financial challenges, disproportionately affecting rural facilities. CONCLUSIONS: Financial disparities between rural and urban nursing homes are not solely due to geographical location, but also stem from structural challenges. These insights have significant policy implications suggesting that addressing reimbursement rates, operational efficiency, and resource allocation is crucial to ensure the financial sustainability and quality care for aging populations.
Use of telehealth did not mitigate persistent disparities in prenatal care access among American Indian women in North Dakota.
Stiller T, Kihlstrom AC, Sultana N … +4 more , Njau G, Schmidt M, Stepanov A, Williams AD
J Rural Health · 2025 Jun · PMID 40692185 · Full text
BACKGROUND: In North Dakota (ND), American Indian (AI) women face a persistent disparity in prenatal care (PNC) access compared to other women. During the COVID pandemic, the expansion of telehealth emerged as a potentia...
BACKGROUND: In North Dakota (ND), American Indian (AI) women face a persistent disparity in prenatal care (PNC) access compared to other women. During the COVID pandemic, the expansion of telehealth emerged as a potential solution to disparate access to health care. We examined whether telehealth use mitigated disparities in PNC in ND. METHODS: Data were drawn from the 2020 to 2021 ND Pregnancy Risk Assessment Monitoring System (weighted n = 10,189). PNC initiation >13 weeks gestation or not receiving PNC was considered "late/no PNC." Maternal race/ethnicity was self-reported. Use of telehealth for prenatal visits was self-reported and categorized as "any telehealth use" versus "no telehealth use." Those not using telehealth self-reported eight barriers to telehealth (e.g., lacking internet, no appointments). Logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) for late/no PNC among AI and other race/ethnicity women compared to White women. Models included maternal sociodemographic and health factors. Chi-square was used to examine prevalence of telehealth barriers by race/ethnicity. RESULTS: Compared to White women, AI/AN women were twice as likely to receive late/no PNC (OR: 2.40; 95% CI, 1.08, 5.35). When telehealth was accounted for, the AI-White disparity was lowered by only 2% (OR: 2.35; 95% CI, 1.05, 5.26). Compared to White and other race/ethnicity women, a higher prevalence of AI/AN women reported a lack of telehealth appointments (p < 0.01), no computers (p < 0.01), no phones (p < 0.01), and no physical space (p < 0.01) as barriers to telehealth. DISCUSSION: The use of telehealth did not mitigate PNC disparities in ND. Infrastructure investments and culturally safe initiatives are needed to improve PNC access for AI/AN women.
An assessment of area-level vulnerability and resilience indices by geography: A rural-urban comparison.
Balio CP, Sullivan OA, Petty EG … +3 more , Pelton B, Dockery N, Beatty KE
J Rural Health · 2025 Jun · PMID 40685557 · Publisher ↗
PURPOSE: Area-level vulnerability and resilience indices combine multiple dimensions of demographic, economic, and environmental factors into a single measure of area-level risk. These indices are widely used to allocate...
PURPOSE: Area-level vulnerability and resilience indices combine multiple dimensions of demographic, economic, and environmental factors into a single measure of area-level risk. These indices are widely used to allocate resources in health care and public health. We investigated how commonly used, existing area-level indices correlate with each other, and how they differ by geography, comparing rural and urban areas. METHODS: Seven publicly available indices were selected for inclusion. Rurality was defined by Rural-Urban Continuum Codes and/or Rural-Urban Commuting Areas, depending on the geographic level of each index. Percentiles were obtained or calculated for each index and compared by rurality. FINDINGS: We find that these area-level indices are not substitutes for each other, and they differ significantly across the rural-urban continuum in conflicting ways. Three different patterns generally emerged from analysis: indices that increase as geography becomes more rural; indices that decrease as geography becomes more rural; and indices with the greatest values among middle levels of geography. CONCLUSIONS: Findings from this work underscore the importance of better understanding how area-level indices may differ across the United States and by specific populations. When using area-level indices in policy and resource allocation, strategic selection and implementation considering differences by rurality may be warranted.
Impact of rural-urban residence and deprivation on care pathways for depression disorders among adults in the UK.
Inghels M, Nelson D, Kane R … +2 more , Gussy M, Deaney C
J Rural Health · 2025 Jun · PMID 40685550 · Full text
PURPOSE: To investigate how rurality shapes individual care pathways and health outcomes for depression and to investigate the sociodemographic and economic relationships with urban-rural variations. METHODS: A retrospec...
PURPOSE: To investigate how rurality shapes individual care pathways and health outcomes for depression and to investigate the sociodemographic and economic relationships with urban-rural variations. METHODS: A retrospective cohort study using routinely collected data from adult patients diagnosed for depression and registered at a general practice in Lincolnshire in the UK. Access and time to access from the onset of depression symptoms to the following care pathway states were described (ie, access to a depression screening tool, confirmed diagnosis, access to treatment and outcomes). Multistate survival analyses were conducted to investigate the effect of the patient's living environment (rural/urban, index of multiple deprivation) on progression through their care pathway for depression. FINDINGS: Overall, 1,111 patients with depression were included. While access to depression services were lower for patients living in rural areas, they were more likely to experience positive depression outcomes, and more quickly, compared to their urban counterparts. Controlled depression and relapse rates were, respectively, 29% lower and 31% higher among urban residents. The level of deprivation was found to have a limited effect on care access, as well as on depression outcomes. CONCLUSION: While accessing care services remains a challenge in rural areas, our study highlights the potential benefits of the rural context in improving depression outcomes and lowering relapse risk. Area-based deprivation had minimal impact on both care access and depression outcomes. Future mental health programs must tailor their strategies to the unique challenges of urban and rural environments to facilitate more effective interventions.
Health information technology in rural health care: A systematic review of its impact on critical access hospitals.
Pai DR
J Rural Health · 2025 Jun · PMID 40678983 · Publisher ↗
OBJECTIVE: This systematic review examines the profound impact of health information technology (HIT) on critical access hospitals (CAHs), focusing on the persistent challenges hindering effective implementation and util...
OBJECTIVE: This systematic review examines the profound impact of health information technology (HIT) on critical access hospitals (CAHs), focusing on the persistent challenges hindering effective implementation and utilization, and their consequences for rural health care. METHODS: Following Primary Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically searched ProQuest, Web of Science, Scopus, and MEDLINE (2000-2024) for peer-reviewed articles, screening titles, abstracts, and full texts. RESULTS: Forty-five studies were included, with a majority (n = 31) published post-Health Information Technology for Economic and Clinical Health (HITECH) Act. Analysis revealed recurring challenges: crippling financial constraints, persistent staffing shortages, and frustrating interoperability failures. Diverse methodologies, including statistical analyses, surveys, case studies, and interviews, underscored the pervasive nature of these issues. DISCUSSION: Beyond financial, human, and interoperability barriers, our review identified key themes related to organizational dynamics and network effects. We discuss critical policy implications, offer actionable recommendations, acknowledge study limitations, and highlight crucial directions for future research. CONCLUSION: This review provides compelling evidence of the urgent need to address the unique HIT adoption challenges facing CAHs. By understanding these barriers and leveraging HIT's potential, we can significantly improve patient care and health equity in vulnerable rural communities. These findings are critical for policymakers, health care leaders, and researchers striving to strengthen rural health care delivery.
Enduring lessons from the COVID-19 pandemic: Advancing virtual care for substance use disorders in rural America.
LaPorte TM, McGinnis S, Lacy G
J Rural Health · 2025 Jun · PMID 40665549 · Publisher ↗
PURPOSE: This study explores how rural substance use disorder (SUD) treatment providers in New York State adapted to pandemic-era policy changes by rapidly adopting virtual care, identifying both challenges and opportuni...
PURPOSE: This study explores how rural substance use disorder (SUD) treatment providers in New York State adapted to pandemic-era policy changes by rapidly adopting virtual care, identifying both challenges and opportunities to inform future practice. METHODS: Thematic analysis of qualitative data from individual interviews with 12 SUD treatment providers and a focus group with an additional 6 providers in rural New York State was conducted between February and May 2021, capturing experiences with virtual care during the COVID-19 pandemic. FINDINGS: The pandemic drove swift virtual care adoption, overcoming some rural barriers to SUD treatment access, like limited transportation and provider shortages. Providers noted enhanced flexibility, allowing more person-centered care adapting to clients' logistical challenges. However, limitations emerged, including digital access disparities, reduced client accountability, and challenges establishing therapeutic relationships-especially for new clients or group sessions. Virtual care effectiveness varied by treatment stage, client demographics, and access to reliable technology. CONCLUSIONS: Although virtual care presents opportunities to expand rural SUD treatment access, a hybrid model combining in-person and virtual care may better meet diverse client needs. Addressing technological inequities and tailoring approaches to individual circumstances are essential for future interventions.
Increasing access to orthotic and prosthetic care in rural communities: Satisfaction with the Department of Veterans Affairs Mobile Prosthetic and Orthotic Care Program.
Leonard C, Feser W, McKown L … +4 more , Whitfield E, Kaufman GE, Abrahamson D, Young J
J Rural Health · 2025 Jun · PMID 40643291 · Publisher ↗
BACKGROUND: In the Veteran's Health Administration (VHA), rural Veterans who need orthotic and prosthetic (O&P) care typically travel to urban VHA medical centers (VAMCs). This presents a barrier to receiving O&P care, a...
BACKGROUND: In the Veteran's Health Administration (VHA), rural Veterans who need orthotic and prosthetic (O&P) care typically travel to urban VHA medical centers (VAMCs). This presents a barrier to receiving O&P care, as travel may be burdensome due to medical or psychosocial issues. The VHA Mobile Prosthetic and Orthotic Care Program (MoPOC) removes access barriers to VHA O&P care by providing care in rural VHA clinics or in Veterans' homes. The goal of this evaluation was to understand if Veterans are satisfied with access to MoPOC care, MoPOC clinicians, and impacts of care. METHODS: We conducted a convergent mixed methods evaluation with a satisfaction survey and qualitative interviews among Veterans who received MoPOC care. Surveys were analyzed descriptively. Interviews were analyzed using rapid matrix analysis. RESULTS: We received 598 survey responses (36% response rate) from six MoPOC sites and conducted 35 interviews. Findings included high Veteran satisfaction with MoPOC clinicians, high satisfaction with MoPOC care, improved access to care, allowing Veterans to stay in the VHA for care, positive impacts on quality of life, and challenges related to timeliness of device delivery. DISCUSSION/SIGNIFICANCE: Veterans were satisfied with MoPOC and MoPOC increased access to care. Many Veterans reported that they would not have received O&P care without MoPOC. This, along with the perceived quality of life impacts, indicates that expanding access to VHA O&P care in rural areas benefits Veterans. Many Veterans preferred to receive care in the VHA, suggesting programs like MoPOC are preferable to outsourcing care to non-VHA settings. Ensuring timeliness of device delivery is a key challenge, and it is unknown how satisfaction of timeliness within the VHA compares to satisfaction with timeliness of device provision in other settings.
Rural and urban differences in family physician burnout before and during the COVID-19 pandemic.
Woolcock SC, Patterson DG, Dunn JA … +2 more , Peterson LE, Andrilla CHA
J Rural Health · 2025 Jun · PMID 40643282 · Publisher ↗
PURPOSE: Understanding the different challenges rural and urban family physicians faced during the COVID-19 pandemic is essential for developing strategies to combat burnout. This study described the prevalence of burnou...
PURPOSE: Understanding the different challenges rural and urban family physicians faced during the COVID-19 pandemic is essential for developing strategies to combat burnout. This study described the prevalence of burnout among rural and urban family physicians before and during the pandemic, examining physician and practice characteristics associated with burnout. METHODS: We conducted a repeated cross-sectional analysis of survey responses of 25,018 family physicians from the American Board of Family Medicine National Graduate Survey and Practice Demographic Survey from 3 time periods: pre-pandemic (January 2019-March 2020), early pandemic (April 2020-April 2021), and later pandemic (May 2021-June 2022). We used bivariate analyses and logistic regression to compare self-reported burnout in rural and urban family physicians over these time periods, controlling for physician and practice characteristics. RESULTS: Overall, 43.5% of family physicians included in this study met the criteria for burnout. The burnout rate was slightly higher for rural physicians (45.2%) compared to urban physicians (43.2%), but not statistically significant. In the adjusted analyses, there was no association of rurality and burnout (adjusted risk ratio [aRR] 1.04, 95% CI 1.00-1.09). Family physicians in the later stage of the pandemic were more likely to report burnout than in the pre-pandemic stage (aRR 1.06, 95% CI 1.02-1.10). CONCLUSIONS: We found burnout was a pervasive concern among family physicians over the stages of the pandemic, although we found no differences in burnout between rural and urban family physicians. Addressing family physician burnout is crucial to maintaining a resilient rural primary care workforce.
Disparities in rural and urban outcomes in populations with human papillomavirus-associated oropharyngeal cancers.
Mills KG, Farrokhian N, Ablah E … +1 more , Sykes KJ
J Rural Health · 2025 Jun · PMID 40637246 · Publisher ↗
IMPORTANCE: There is a need to understand how the increasing rate of HPV-positive oropharyngeal cancers may affect underresourced populations. PURPOSE: To investigate possible disparities in survival and cause-specific m...
IMPORTANCE: There is a need to understand how the increasing rate of HPV-positive oropharyngeal cancers may affect underresourced populations. PURPOSE: To investigate possible disparities in survival and cause-specific mortality between rural and urban populations with HPV-associated oropharyngeal cancer. DESIGN: Our retrospective cohort study utilized the Surveillance, Epidemiology, and End Results (SEER) Pharyngeal Cancer with HPV Status Database from 2006 to 2018. Cox proportional hazard models and Kaplan-Meier curves were employed to evaluate the differences in overall survival and cause-specific mortality. SETTING: SEER data used in this study originate from a set of regional cancer registries located across the country. PARTICIPANTS: Patients diagnosed with HPV-associated oropharyngeal cancer from 2006 through 2018 in the SEER HPV status database. MAIN OUTCOME(S) AND MEASURE(S): The difference in overall survival and cause-specific mortality between rural and urban populations with HPV-associated oropharyngeal cancer. RESULTS: A total of 13,294 patients were included in our study, most of whom lived in urban counties (88.5%, n = 11,766), had a mean age of 60.6 years (SD = 9.6), and had a primary tumor site located in the tonsil (47.6%, n = 6328). Rural communities had a higher likelihood of all-cause mortality (hazard ratio [HR] 1.14, 95% confidence interval [CI], 1.02-1.29) compared to their urban counterparts. Additionally, rural residents had a higher probability of cause-specific mortality (HR 1.15, 95% CI, 1.01-1.32) compared to their urban counterparts. CONCLUSIONS: Patients with HPV-associated oropharyngeal cancer who reside in rural areas were more likely to die when compared to their urban counterparts. More research is needed to determine the best way to mitigate this disparity.
Colorectal cancer survival disparities in persistent poverty areas.
DelNero P, Schootman M, Peng C … +4 more , Saini M, Hallgren E, Laryea J, Li C
J Rural Health · 2025 Jun · PMID 40629554 · Full text
PURPOSE: We examined whether living in persistent poverty census tracts was associated with disparities in colorectal cancer (CRC) survival and whether the association varied between urban and rural settings. METHODS: Us...
PURPOSE: We examined whether living in persistent poverty census tracts was associated with disparities in colorectal cancer (CRC) survival and whether the association varied between urban and rural settings. METHODS: Using 2013-2019 state-wide cancer registry and 2013-2021 death records data, CRC patients were classified by tract-level persistent poverty and rural/urban status. Overall and CRC-specific survival were compared using Kaplan-Meier estimation and log-rank tests. Adjusted analyses were conducted using Cox proportional hazard and Fine-Gray competing risk models. FINDINGS: During the study period, 558 (53%) of 1055 CRC patients died in persistent poverty tracts versus 3117 (45%) of 6938 patients in nonpersistent poverty tracts. Of the 3675 deaths, 2269 (61.7%) were from CRC-specific causes. In unadjusted analysis, CRC patients in persistent poverty areas had a higher risk of all-cause (HR, 95%CI: 1.28, 1.17-1.40) and CRC-specific (HR, 95% CI: 1.17, 1.04-1.31) mortality. After covariates adjustment, the relationship between persistent poverty and all-cause mortality (HR, 95% CI: 1.17, 1.06-1.29) and non-CRC-specific mortality (HR, 95% CI: 1.34, 1.15-1.57) remained significant, but CRC-specific mortality did not. In subgroup analyses, persistent poverty was associated with increased overall mortality among urban tracts (HR, 95% CI: 1.22, 1.08-1.38), but not rural tracts. CONCLUSIONS: After covariates adjustment, CRC patients in persistent poverty tracts are more likely to die of all causes and non-CRC causes but not CRC-specific causes than those in nonpersistent poverty areas, suggesting that differences in CRC-specific deaths may be partly attributed to demographics, geography, tumor characteristics, and treatment.
Insights into suicidality in rural communities: Lessons from Rawat et al. (2025) and perspectives from Alaska and Colorado.
Lockhart ENS
J Rural Health · 2025 Jun · PMID 40588832 · Publisher ↗
Abstract loading — click title to view on PubMed.
Impact of rurality and the area deprivation index on outcomes of collaborative care for depression.
Savitz ST, Chamberlain AM, Jiang R … +2 more , Sarwar S, Williams MD
J Rural Health · 2025 Jun · PMID 40545556 · Publisher ↗
PURPOSE: The Collaborative care model (CoCM) is the leading model for integrating behavioral health into primary care for patients with major depressive disorder (MDD). However, CoCM requires engagement and ongoing parti...
PURPOSE: The Collaborative care model (CoCM) is the leading model for integrating behavioral health into primary care for patients with major depressive disorder (MDD). However, CoCM requires engagement and ongoing participation. We aimed to assess whether two area-based measures, the area-deprivation index (ADI) and rurality, were associated with enrollment, participation, and outcomes with CoCM. METHODS: This was an observational analysis of Mayo Clinic patients eligible for CoCM: adults aged ≥18 years, empaneled in primary care, and with a PHQ-9 of ≥10. We operationalized ADI as quintiles with Q1 being least deprived and Q5 being most deprived and rurality using RUCA codes with two categories: urban and rural. We evaluated enrollment in CoCM, drop out defined by leaving the program early, the count and type of contacts with the care coordinator, and clinical improvement measured using the PHQ-9. FINDINGS: We identified 54,030 individuals with 16,532 (30.6%) residing in rural areas and 11,122 (20.6%) residing in the most deprived ADI quintile (Q5). Living in a rural area was associated with lower enrollment in CoCM (-2.3 percentage points [95% confidence interval (CI): -2.5, 2.2]), longer length in CoCM (18.6 days [95% CI: 5.7, 31.5]), more contacts with the care coordinator (1.1 contacts [95% CI: 0.2, 2.0]), and worse response and remission. In contrast, ADI Q5 was only associated with worse response and remission. CONCLUSIONS: Rurality was associated with lower enrollment, greater engagement, and worse clinical outcomes. More work may be needed to address enrollment barriers for individuals living in rural areas to improve clinical outcomes.
An exploratory study to understand how rurality status and demographic characteristics are associated with enrollment, engagement, and retention in a digital health intervention targeting the Appalachian region.
Brock DP, Ritterband LM, You W … +4 more , Reid AL, Porter KJ, Markwalter T, Zoellner JM
J Rural Health · 2025 Mar · PMID 40515483 · Full text
PURPOSE: Digital health studies exploring group disparities across research phases are limited. As a secondary aim of a larger digital health trial, this study explored how rurality and other sociodemographics were assoc...
PURPOSE: Digital health studies exploring group disparities across research phases are limited. As a secondary aim of a larger digital health trial, this study explored how rurality and other sociodemographics were associated with enrollment, retention, and engagement in a randomized controlled sugar-sweetened beverage (SSB) reduction trial. METHODS: Participants from a primarily Appalachian sample were randomized into iSIPsmarter (experimental) or static Patient Education (control) websites. Enrollment, retention (6 months), and iSIPsmarter engagement (completion of metered program Core content and SSB and weight diaries) were collected from July 2021 to August 2023. Regression models assessed subgroup associations using Rural Urban Continuum Codes (RUCC), sex, race, age, income, education, and other sociodemographic predictors. FINDINGS: Of the 509 eligible participants, 249 (49%) enrolled, and 218 (88%) were retained. Participants were predominantly White (89%), college-educated (59%) females (83%) with household incomes <$55,000/year (52%). Rurality varied: RUCC 1-2 (medium-large metro) = 15%, RUCC 3 (small metro) = 45%, and RUCC 4-9 (nonmetro) = 41%. On average, iSIPsmarter participants (n = 127) completed 4.89/6 (SD = 1.69) Cores and 76% (SD = 29%) and 57% (SD = 31%) of SSB and weight diaries. Rurality was a nonsignificant predictor, but higher education and health literacy increased enrollment likelihood by 37% (95% CI = 1.12-1.67) and 23% (95% CI = 1.03-1.47), respectively. Greater education (OR = 1.51, 95% CI = 1.00-2.29), age (OR = 1.04, 95% CI = 1.01-1.07), and income (OR = 1.13, 95% CI = 1.00-1.28) significantly predicted retention. Older age significantly (P<.05) predicted the completion of Cores and diaries. CONCLUSIONS: Results suggested rurality was not significantly associated with enrollment, retention, or engagement, though this conclusion warrants caution. Future digital health studies targeting similar populations should consider additional sociodemographic differences.
Geographic disparities in unpaid caregiving.
Boswell EK, Brown MJ, Donelle L … +4 more , Yell N, Farrell T, Hung P, Crouch E
J Rural Health · 2025 Mar · PMID 40515480 · Full text
PURPOSE: An updated, nationally representative examination of rural-urban differences in the experiences, health, and well-being of caregivers is needed; previous research on this topic uses older data or has limited gen...
PURPOSE: An updated, nationally representative examination of rural-urban differences in the experiences, health, and well-being of caregivers is needed; previous research on this topic uses older data or has limited generalizability. This study examines rural-urban differences in the characteristics, experiences, and health of caregivers. METHODS: The 2021-2022 Behavioral Risk Factor Surveillance System (n = 44,274 unpaid caregivers) was used, with rurality defined according to the 2013 National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme. Chi-square tests compared rural-urban differences in these caregivers' characteristics, including demographic factors, caregiving intensity (e.g., weekly hours spent caregiving, reason for caregiving, past-month ADL/IADL assistance), caregiver's health (e.g., general health status and past month physical health, mental health, and limited activity), and caregiver's health behavior (chronic illness, smoking status, binge drinking, and annual checkups). FINDINGS: Compared to urban caregivers, rural caregivers were more likely to have at least one chronic condition (58.3% vs. 53.2%; p < 0.0001), be obese (42.9% vs. 37.5%; p < 0.0001), be a smoker (24.2% vs. 15.5%; p < 0.0001), and less likely to be a binge drinker (12.7% vs. 15.3%; p = 0.003). Compared to urban caregivers, rural caregivers were more likely to report their general health status as fair/poor (20.3% vs. 17.0%, p = 0.0003) and were more likely to report 14 or more days of poor physical health in the past month (15.6% vs. 12.0%, p < 0.0001). CONCLUSIONS: Understanding geographic disparities in the experiences and context of unpaid caregiving is needed to improve their overall well-being and health. Future research will be necessary to determine factors associated with these outcomes.
The impact of California Proposition 56 on smoking behaviors across geographic residence.
Keeler C, Curtis AC
J Rural Health · 2025 Mar · PMID 40515468 · Publisher ↗
PURPOSE: To explore the geographic impact of California's Proposition 56 (Prop 56) on smoking behaviors. METHODS: We identified 61,193 respondents aged 21+ from the 2012-2018 California Behavioral Risk Factor Surveillanc...
PURPOSE: To explore the geographic impact of California's Proposition 56 (Prop 56) on smoking behaviors. METHODS: We identified 61,193 respondents aged 21+ from the 2012-2018 California Behavioral Risk Factor Surveillance Survey. We constructed county identifiers indicating whether (1) a respondent lived in an urban, suburban, or rural county and (2) whether a respondent lived in a metropolitan statistical area (MSA) or not. Similarly, we created a binary variable indicating whether Prop 56 was in effect (Yes/No). We used a two-part model to estimate the association of Prop 56 with smoking participation among all adults and smoking intensity (average number of cigarettes smoked per day (CPD)) among current smokers. Models were run separately for each geographic subgroup. Additional covariates included sociodemographic characteristics and a time trend variable. FINDINGS: Smoking prevalence was significantly different across geographic groups, with rates highest among the rural population group (13.8%) and lowest among the urban subgroup (9.1%). Similarly, rates of smoking intensity were significantly higher among non-urban populations, with average CPD highest among the rural population (10.66) and lowest among the urban subgroup (8.32). Regression models highlighted a negative association between Prop 56 and smoking participation only among the urban and MSA subgroups (p < 0.001). We found no evidence of an association between the enactment of Prop 56 with average CPD for any geographic group. CONCLUSION: Public health experts, clinicians, and policymakers might consider additional interventions that can be implemented in tandem with pricing tools to help reduce observed geographic disparities in smoking among rural-and even suburban-communities.
Phone-only mental health care within the Department of Veterans Affairs: Associations with rurality, age, sex, and clinical severity.
Connolly SL, Amspoker AB, Walder A … +5 more , Grubbs KM, Chen L, Ecker AH, Hogan JB, Lindsay JA
J Rural Health · 2025 Mar · PMID 40515466 · Publisher ↗
OBJECTIVE: This study explores factors associated with an increased likelihood of receiving mental health (MH) care exclusively via audio-only phone visits within the Department of Veterans Affairs (VA). METHODS: Include...
OBJECTIVE: This study explores factors associated with an increased likelihood of receiving mental health (MH) care exclusively via audio-only phone visits within the Department of Veterans Affairs (VA). METHODS: Included patients had ≥1 VA MH outpatient encounter between October 1, 2021-September 30, 2022 and October 1, 2022-September 30, 2023. Patients were divided into a "phone only" group and an "all other" group, which encompassed all patients who did not exclusively receive phone care, including video and/or in-person care. Logistic regression models evaluated demographic and clinical predictors of receiving MH care via phone only. RESULTS: The sample included 1,156,146 patients; 49,125 (4.25%) in the phone only group and 1,107,021 (95.75%) in the all other group. The following were associated with greater odds of receiving MH care via phone only in a multivariate model, all Ps<.0001: being highly rural (OR = 1.50), age 65+ (ORs ≥2.17), with fewer than 3 MH diagnoses (OR = 2.03), and >50% of MH visits conducted by a medical MH provider (OR = 1.87). CONCLUSIONS: Patients who were rural and older had greater odds of receiving MH care exclusively by phone. It will be important to assess whether this was by choice or whether they are experiencing barriers to accessing video or in-person care that could be addressed. Patients who were less clinically severe and were seen primarily by a medical MH provider were also more likely to receive phone-only care. Future research should examine the relative effectiveness of audio-only care as compared to video and in-person.
Evolution of the US nonmetropolitan mortality disadvantage by sex, state, and year, 1999-2019.
Paglino E, Elo IT, Preston SH … +2 more , Hempstead K, Stokes AC
J Rural Health · 2025 Mar · PMID 40515425 · Full text
PURPOSE: To examine disparities in nonmetropolitan and metropolitan mortality by state and sex from 1999 to 2019. METHODS: We calculate age-standardized mortality rates for nonmetropolitan and metropolitan areas by state...
PURPOSE: To examine disparities in nonmetropolitan and metropolitan mortality by state and sex from 1999 to 2019. METHODS: We calculate age-standardized mortality rates for nonmetropolitan and metropolitan areas by state and sex and compute age-standardized differences in these rates within each state and relative to the national average. We further estimate the number of excess deaths in nonmetropolitan areas by state. These are deaths that would have been avoided if nonmetropolitan areas had the same age-specific death rates as metropolitan areas in the same state. FINDINGS: We document increasing nonmetropolitan mortality disadvantage since 1999 along with significant variation in the magnitude and timing of its emergence by state. Although stagnation in mortality was observed nationally in the mid-2010s, this was not true in all states or in all metropolitan and nonmetropolitan areas. Additionally, mortality trends became progressively more discordant across and within states. Despite this heterogeneity, we document a steady increase in the number of nonmetropolitan excess deaths from 8,400 in 1999 to 47,000 in 2019, representing 9.0% of all nonmetropolitan deaths. CONCLUSIONS: National-level mortality trends mask geographic variation by nonmetropolitan and metropolitan areas within and across states. Further research is needed to identify factors that contribute to these divergent patterns.
Exploring telehealth adoption and financial outcomes for rural hospitals during the COVID-19 public health emergency.
Karim SA, Tilford JM, Bogulski CA … +2 more , Hayes CJ, Eswaran H
J Rural Health · 2025 Mar · PMID 40432258 · Publisher ↗
PURPOSE: To examine factors associated with rural hospital telehealth adoption during the COVID-19 public health emergency (PHE), and evaluate its relationship with rural hospital financial performance before and during...
PURPOSE: To examine factors associated with rural hospital telehealth adoption during the COVID-19 public health emergency (PHE), and evaluate its relationship with rural hospital financial performance before and during the PHE. METHODS: This panel study used retrospective data (2017-2021) from the American Hospital Association Annual Survey, the Centers for Medicare & Medicaid Services Healthcare Cost Report Information Systems, and the Area Health Resource File. Rural hospitals were categorized as persistent adopters, persistent nonadopters, or switchers based on telehealth adoption status. Bivariate analyses assessed differences in subgroup means and frequencies, while a difference-in-difference model estimated the impact of telehealth adoption on rural hospital financial performance. FINDINGS: Telehealth adoption varied among rural hospitals. Before the PHE, 75% (751) of rural hospitals had adopted telehealth, while 25% (247) were nonadopters. Despite efforts to promote remote care delivery during the PHE, 58% (144) of pre-PHE nonadopters did not adopt telehealth. Among the 42% (103) that did adopt telehealth during the PHE, no statistically significant effect was observed on operating or total margins. CONCLUSION: Rural hospitals in economically disadvantaged and sparsely populated areas, which stand to benefit the most from telehealth adoption, often face substantial barriers that limit their ability to adopt this technology. Financial constraints and limited resources continue to hinder adoption, underscoring the need for targeted policies and investments to expand telehealth access and improve health care outcomes in rural communities.
Obstetric care in rural critical access hospitals: A domestic application of the World Health Organization Emergency Obstetric Care framework in rural communities.
Glover AL, Brown D, Holman C … +1 more , Nelson M
J Rural Health · 2025 Mar · PMID 40411254 · Full text
PURPOSE: Pregnancy-related mortality has increased steadily over the last 30 years in the United States; during the same period, rural communities have lost access to care as rural hospitals and obstetric units have shut...
PURPOSE: Pregnancy-related mortality has increased steadily over the last 30 years in the United States; during the same period, rural communities have lost access to care as rural hospitals and obstetric units have shut their doors. Rural critical access hospitals (CAHs) are often the only option for a pregnant person in a rural community needing emergency care. This study aimed to apply a uniform assessment of the capacity of hospitals that do not have obstetric units to meet the emergency obstetric care needs of the rural communities they serve, with the goal of facilitating ongoing obstetric emergency readiness assessments that can be used in the rural context. METHODS: The study team conducted facility assessments across Montana's statewide system of hospital care. The Centers for Disease Control and Prevention (CDC) Levels of Care Assessment Tool (LOCATe) was used in hospitals with an obstetrics unit (N = 25). The team adapted the World Health Organization (WHO) Emergency Obstetric Care (EmOC) framework to assess readiness in hospitals without an obstetrics unit (N = 34) but with Emergency Medical Treatment and Labor Act (EMTALA)-based obligations to patients presenting to emergency departments with obstetric emergencies. FINDINGS: None of the responding hospitals without obstetric units met criteria indicating readiness to provide comprehensive emergency obstetric care (CEmOC), and only one hospital met criteria indicating readiness to provide basic emergency obstetric care (BEmOC). CONCLUSION: Significant work must be done to bring CAHs up to a level of readiness where they can safely and effectively screen, stabilize, and transfer or accept an obstetric emergency. The WHO EmOC framework can provide a starting point for assessing the capacity of hospitals without obstetric units, but a standardized assessment, such as LOCATe, should be developed to improve readiness for obstetric emergencies.
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