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Context: Very little population-based research has examined health and access to care among transgender populations. This study compared barriers to care between cisgender, transgender, and gender nonconforming (GNC) adults using data from a large, multistate sample. Methods: We used data from the 2014-2015 Behavioral Risk Factor Surveillance System to estimate the prevalence of having no health insurance, unmet medical care needs due to cost, no routine checkup, and no usual source of care for cisgender women (n = 183,370), cisgender men (n = 131,080), transgender women (n = 724), transgender men (n = 449), and GNC adults (n = 270). Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for each barrier to care while adjusting for sociodemographic characteristics. Findings: Transgender and GNC adults were more likely to be nonwhite, sexual minority, and socioeconomically disadvantaged compared to cisgender adults. After controlling for sociodemographic characteristics, transgender women were more likely to have no health insurance (OR = 1.60; 95% CI = 1.07-2.40) compared to cisgender women; transgender men were more likely to have no health insurance (OR = 2.02; 95% CI = 1.25-3.25) and no usual source of care (OR = 1.84; 95% CI = 1.18-2.88); and GNC adults were more likely to have unmet medical care needs due to cost (OR = 1.93; 95% CI = 1.02-3.67) and no routine checkup in the prior year (OR = 2.41; 95% CI = 1.41-4.12). Conclusions: Transgender and GNC adults face barriers to health care that may be due to a variety of reasons, including discrimination in health care, health insurance policies, employment, and public policy or lack of awareness among health care providers on transgender-related health issues.

Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than twenty-eight million women of reproductive age living in rural America. Yet the extent of recent obstetric unit closures has not yet been measured. Using national data, we found that 9 percent of rural counties experienced the loss of all hospital obstetric services in the period 2004-14. In addition, another 45 percent of rural US counties had no hospital obstetric services at all during the study period. That left more than half of all rural US counties without hospital obstetric services. counties with fewer obstetricians and family physicians per women of reproductive age and per capita, respectively; a higher percentage of non-Hispanic black women of reproductive age; and lower median household incomes and those in states with more restrictive Medicaid income eligibility thresholds for pregnant women had higher odds of lacking hospital obstetric services. The same types of counties were also more likely to experience the loss of obstetric services, which highlights the challenge of providing adequate geographic access to obstetric care in vulnerable and underserved rural communities.

The internet has emerged as a main venue of health information delivery and health-related activities. However, few studies have examined how health literacy determines online health-related behavior. The aim of this study was to investigate the current level of health-related information-seeking using the internet and how health literacy, access to technology, and sociodemographic characteristics impact health-related information-seeking behavior. We conducted a cross-sectional study through a survey with Minnesotan adults (N=614) to examine their health literacy, access to technology, and health-related information-seeking internet use. We used multivariate regression analysis to assess the relationship between health-related information-seeking on the internet and health literacy and access to technology, controlling for sociodemographic characteristics. Better health literacy (β=.35, SE 0.12) and greater access to technological devices (eg, mobile phone and computer or tablet PC; β=.06, SE 0.19) were both associated with more health-related information-seeking behavior on the internet after adjusting for all other sociodemographic characteristics. Possession of a graduate degree (β=.28, SE 0.07), female gender (β=.15, SE 0.05), poor health (β=.22, SE 0.06), participation in social groups (β=.13, SE 0.05), and having an annual health exam (β=.35, SE 0.12) were all associated with online health-related information-seeking. Our findings indicate that access to online health-related information is not uniformly distributed throughout the population, which may exacerbate disparities in health and health care. Research, policy, and practice attention are needed to address the disparities in access to health information as well as to ensure the quality of the information and improve health literacy.

Despite well-documented health disparities by rurality and race/ethnicity, research investigating racial/ethnic health differences among US rural residents is limited. We used county-level data to measure and compare premature death rates in rural counties by each county’s majority racial/ethnic group. Premature death rates were significantly higher in rural counties with a majority of non-Hispanic black or American Indian/Alaska Native (AI/AN) residents than in rural counties with a majority of non-Hispanic white residents. After we adjusted for community-level covariates, differences in premature death remained significant in counties with a majority of AI/AN residents but not those with a majority of non-Hispanic black residents. This study highlights the particular vulnerability of non-Hispanic black and AI/AN rural communities to high rates of premature mortality. Policies to improve rural health should focus on these racially diverse communities, addressing economic vitality and current and historical political context to mitigate health inequities and the harmful health effects of neglecting social determinants of health.

Although skin cancers are considered mostly preventable, more people in the US are diagnosed with skin cancer than all other cancers combined. Sun safety recommendations include wearing sun-protective clothing, a wide-brimmed hat, seeking shade, and using sunscreen. Some evidence exists that sun risk behaviors and skin cancer rates are more frequent among rural than urban US populations, raising questions about underlying factors. We conducted a belief elicitation survey on these four sun protection behaviors among 278 adults (aged 18–60 years) living in rural Minnesota, a state with high sunburn rates and UV-attributable melanoma cases. These qualitative data were analyzed using content analysis, and the identified codes ranked by frequency. Almost all participants emphasized that spending time outside was important to them. The most frequently reported sun protection behaviors were wearing sunscreen and protective clothing. The primary outcomes were obtained from open-ended questions on outcome, normative, and control beliefs associated with each sun protection behavior. While many different beliefs were mentioned, reducing sunburn and skin cancer risk were commonly reported across all behaviors. Beliefs about negative aspects of each behavior (e.g., interference with being physically active or doing work outside, greasy/sticky sunscreen, not getting a suntan, overheating in long clothes or when wearing hats, hats that blow off easily) typically outnumbered positive aspects (e.g., protective behaviors enabling being outside, staying cool in shade, reduced skin aging). The majority of participants believed that most people would approve of all protection behaviors, but many thought that age was a factor for behavior adoption, with young people typically thought to engage less in protective behaviors. Some commonly reported negative aspects of sun protective behaviors were related to activities more common in rural populations, such as working outside. This suggests that rural sun protection promotion may include structural interventions to make sun protection easy, convenient, and accessible without impeding rural lifestyles.

Rural residents are older, on average, than urban residents, with more underlying health conditions and higher rates of disability. Rural nursing homes face unique challenges admitting medically-complex patients and meeting their needs throughout their stay. These challenges may be amplified for certain health conditions. Greater geographic distances also strain transitional care coordination practices with health system referral hubs in urban areas. In this study, we assess perceptions of difficulty rural nursing homes encounter in admitting and serving individuals with dementia, obesity, mental and behavioral health conditions, and medically complex conditions. Using a survey of nursing home administrators located in non-metropolitan counties across the U.S. (n = 209), we assessed the self-reported degree of difficulty identified in serving each of the 4 type of conditions, coupled with qualitative analysis of open-ended questions identifying specific challenges. Rural nursing homes have capacity constraints owing to lower population density, limited financial resources, and unique challenges recruiting and retaining workforce to rural areas. Nursing home administrators reported the most challenges to providing high-quality care to residents with mental and behavioral health challenges, followed by obesity. For specific challenges, administrators focused primarily on staffing concerns, as well as space and equipment needs. Rural nursing home administrators identified challenges related to specific conditions and capacity constraints. To ensure appropriate and highquality nursing home placement for rural residents, and to minimize the disruption of transitions into nursing home settings, more attention is needed on addressing the constraints identified by rural nursing home administrators in this study.

Most Americans know little about options for long-term services and supports and underestimate their likely future needs for such assistance. Using data from the 2012 National Health Interview Survey, we examined expectations about future use of long-term services and supports among adults ages 40-65 and how these expectations varied by current living arrangement. We found differences by living arrangement in expectations about both future need for long-term services and supports and who would provide such care if needed. Respondents living with minor children were the least likely to expect to need long-term services and supports and to require paid care if the need arose. In contrast, respondents living alone were the most likely to expect that it was \"very likely\" that they would need long-term services and supports and to rely on paid care. Overall, we found a disconnect between expectations of use and likely future reality: 60 percent of respondents believed that they were unlikely to need long-term services and supports in the future, whereas the evidence suggests that nearly 70 percent of older adults will need them at some point. These findings both underscore the need for programs that encourage people to plan for long-term services and supports and indicate that information about living arrangements can be useful in developing and targeting such programs.

Purpose Precepting is an essential component of health professional educational programs, yet barriers exist for the recruitment and retention of preceptors. Our goal was to determine the incidence of precepting by physicians, physician assistants (PAs), and advanced practice registered nurses (APRNs) in Minnesota; whether the incidence of precepting varies by region or work setting; and to identify the factors that motivate or inhibit precepting. Method A survey study of physicians, PAs, and APRNs in Minnesota from February 9, 2023 through March 6, 2024. The survey was conducted at the time of health care professional (HCP) license renewal to determine the incidence, work setting, region, motivators, and inhibitors of healthcare precepting. The primary outcome was the incidence of precepting with other variables being work setting, region, motivators, and inhibitors. Results A total of 18,021 health care professionals were surveyed including 12,530 physicians, 3,073 PAs, and 2418 APRNs. The response rate was 97.4%. Across all professions, work settings, and regions the incidence of precepting was 67% (APRNs 70.7%; physicians 68.2%; PAs 61.2%). Precepting was more common in rural (73.6%) versus urban areas (66.9%); and at hospitals (75.6%) versus clinics (61.5%), long-term care (56.7%), or community settings (58.2%). The main motivators for precepting were intrinsic (because they enjoyed it and/or had a personal desire to serve the profession). For those that did not precept, the most common reasons were having no time in their schedule and not being paid to precept. Conclusions The majority of HCPs in Minnesota precept learners. The sites with the highest proportion of precepting were rural clinics and urban hospitals. Intrinsic factors were the major reason given for the decision to precept, with extrinsic factors playing a minor role in these decisions, but a major role for those that did not precept. Our results suggest organizational solutions could enhance the recruitment of preceptors. Keywords: shortage of preceptors; rural preceptors; clinical precepting and training.

Structural resources, including access to health insurance, are understudied in relation to the stress process. Disability increases the likelihood of mental health problems, but health insurance may moderate this relationship. We explore health insurance coverage as a moderator of the relationship between disability and psychological distress. A pooled sample from 2008 to 2010 (N = 57,958) was obtained from the Integrated Health Interview Series. Chow tests were performed to assess insurance group differences in the association between disability and distress. Results indicated higher levels of distress associated with disability among uninsured adults compared with their peers with public or private insurance. The strength of the relationship between disability and distress was weaker for persons with public compared with private insurance. As the Affordable Care Act is implemented, decision makers should be aware of the potential for insurance coverage, especially public, to ameliorate secondary conditions such as psychological distress among persons who report a physical disability.

To examine rural-urban differences in motor vehicle fatality (MVF) risk factors. We used 2017 County Health Rankings data to run stratified regression models to estimate county-level correlates of motor vehicle fatalities (MVFs) by rural and urban location. Rural counties have higher rates of MVFs than urban counties (22 vs. 14 per 100,000, <0.001). Physical inactivity and uninsurance were associated with higher rates of MVFs, as was having a more racially or ethnically concentrated population and larger percentages of younger or older adults. Interventions to reduce MVFs should take geographic location and population composition into account.