David Hartley - Academia.edu (original) (raw)

Papers by David Hartley

Obesity Surgery, Jan 6, 2010

Morbid obesity is associated with serious health and social consequences, high medical costs and ... more Morbid obesity is associated with serious health and social consequences, high medical costs and is increasing in the USA, particularly among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long-term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, insurance categories, socioeconomic, and comorbidity levels. We examined 159,116 records representing 774,000 patients with morbid obesity from the 2006 Nationwide Inpatient Sample. We determined the likelihood, expressed in odds ratios, of bariatric surgery associated with each patient characteristic using survey-weighted univariate logistic regression. We also performed multivariate logistic regression, assuming all patient factors were independent. After adjusting for patient-level characteristics, the most rural residents were 23% less likely to receive bariatric surgery than urban residents. Other demographic features associated with significantly lower odds ratios for bariatric surgery included minority status, male gender, lower income, older age, non-private insurance status, and higher comorbidity. Rural-dwelling patients who are non-white, male, poorer, older, sicker, and non-privately insured almost never received bariatric surgery (OR = 0.0089). Though obesity is more prevalent among middle-aged, rural, economically disadvantaged, and racial/ethnic minority populations, these patients are unlikely to access bariatric surgery. Because obesity is a leading cause of preventable morbidity and mortality in the USA, effective treatments should be made available to all patients who might benefit. Current Medicare/Medicaid policies that reimburse only high volume centers may effectively deny rural residents who rely on these insurance programs for bariatric surgery.

American Journal of Public Health, Jun 1, 1992

Childhood Obesity, 2011

Abstract Background: the food environment, including access to retail food outlets and the presen... more Abstract Background: the food environment, including access to retail food outlets and the presence of healthy food in the home, has been shown to be associated with eating behavior and obesity, but this relationship is not well understood in rural locations. ...

Rural and Remote Health, 2011

Childhood obesity rates appear to be more pronounced among youth in rural areas of the USA. The a... more 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. 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. 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'. 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.

Psychiatric Services, Oct 7, 2014

Linking primary care with psychiatric care has long been promoted as a way to improve access to r... more Linking primary care with psychiatric care has long been promoted as a way to improve access to rural mental health services. The authors describe a national survey that identified 53 successfully linked programs, ranging from small local efforts to sophisticated multicounty networks. Findings indicated that lessons from successful integrations are not easily reduced to a how-to list. Organizations cooperate with each other when it is in their interests to do so. Motivation to integrate cannot be mandated, nor is the availability of funding alone sufficient to provide motivation. The authors discuss ways that managed care may facilitate or hinder the link between rural primary care and rural psychiatry.

This book provides a summary and background of the current state of rural mental health and speci... more This book provides a summary and background of the current state of rural mental health and special consideration in working with rural populations. Chapters discuss some of the major models of service delivery that have been developed to address specific challenges faced in the delivery of quality mental health services. Finally, the book examines specific considerations and best practices for working with distinct subgroups in rural areas, ranging from minority groups to veterans. The book concludes with a discussion on the next steps in advancing the mental health of rural groups. This chapter on Substance Use and Abuse in Rural America looks at the prevalence of substance use and abuse in rural areas compared with urban, efforts to prevent substance use and abuse, treatment availability and accessibility, and continuing care and long-term support for abstinence. It also presents models of service delivery that address resource limitations common to rural areas.

Administration and policy in mental health, 1998

This paper presents findings from a study designed to identify and describe models for integratin... more This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models--diversification, linkage, referral and enhancement--which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.

Current Obesity Reports, 2015

Within most developed countries, rural residents are more likely to be obese and overweight compa... more Within most developed countries, rural residents are more likely to be obese and overweight compared to their urban counterparts. Studies of specific rural communities have found that the limited availability of healthy foods in the community and home as well as individual characteristics and preferences contribute to poor diet and overweight. The rural food environment is varied and may be affected by climate, regional and cultural preferences, transportation access, and remoteness among other factors. Given this diversity and the vulnerabilities of rural residents, who are more likely to have low-income, substandard housing or low educational attainment compared to their urban counterparts, policy and programmatic interventions should target specific needs and communities. This review will describe the rural community, home, and individual food environments and what is known about their roles in healthy eating.

Psychiatric Services, 2010

This study investigated inpatient psychiatric units in small rural hospitals to determine their c... more 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. 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. 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). 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.

Obesity Surgery, 2010

Morbid obesity is associated with serious health and social consequences, high medical costs and ... more Morbid obesity is associated with serious health and social consequences, high medical costs and is increasing in the USA, particularly among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long-term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, insurance categories, socioeconomic, and comorbidity levels. We examined 159,116 records representing 774,000 patients with morbid obesity from the 2006 Nationwide Inpatient Sample. We determined the likelihood, expressed in odds ratios, of bariatric surgery associated with each patient characteristic using survey-weighted univariate logistic regression. We also performed multivariate logistic regression, assuming all patient factors were independent. After adjusting for patient-level characteristics, the most rural residents were 23% less likely to receive bariatric surgery than urban residents. Other demographic features associated with significantly lower odds ratios for bariatric surgery included minority status, male gender, lower income, older age, non-private insurance status, and higher comorbidity. Rural-dwelling patients who are non-white, male, poorer, older, sicker, and non-privately insured almost never received bariatric surgery (OR = 0.0089). Though obesity is more prevalent among middle-aged, rural, economically disadvantaged, and racial/ethnic minority populations, these patients are unlikely to access bariatric surgery. Because obesity is a leading cause of preventable morbidity and mortality in the USA, effective treatments should be made available to all patients who might benefit. Current Medicare/Medicaid policies that reimburse only high volume centers may effectively deny rural residents who rely on these insurance programs for bariatric surgery.

The Journal of Rural Health, 2008

Purpose: Addressing substance abuse in rural America requires extending our understanding beyond ... more Purpose: Addressing substance abuse in rural America requires extending our understanding beyond urban-rural comparisons to how substance abuse varies across rural communities of different sizes. We address this gap by examining substance abuse prevalence across 4 geographic levels, focusing on youth (age 12-17 years) and young adults (age 18-25 years). Methods: The analysis is based on 3 years (2002)(2003)(2004) of pooled data from the National Survey on Drug Use and Health. We measure rurality using a four-tier consolidation of the 2003 Rural-Urban Continuum Codes: urban, rural-adjacent, rural-large, and rural-small and medium. Findings: Rural youth have higher alcohol use and methamphetamine use than urban youth and the more rural the area, the higher the use. Rural young adults living in rural-large areas have higher rates of substance abuse than their urban peers; those living in the most rural areas have nearly twice the rate of methamphetamine use as urban young adults. Rural youth are more likely than urban youth to have engaged in the high-risk behavior of driving under the influence of alcohol or other illicit drugs. Conclusions: Higher prevalence rates, coupled with high-risk behavior, place rural youth and young adults at risk of continued substance use and problems associated with this use. Rural community infrastructure should be enhanced to support substance abuse prevention and intervention for these populations.

The Journal of Rural Health, 2009

The Journal of Rural Health, 2002

This article seeks to identify current research priorities in the area of rural behavioral healfh... more This article seeks to identify current research priorities in the area of rural behavioral healfh. The method for accomplishing this task begins by identifying several domains where policy has a potential to effect improzmnents in access or quality but has been hampered by lack of empirical kmledge. In each domain a synthesis of current research summarizes what is known and draws attention to knowledge gaps. Research questions in each domain are proposed. The policy domains are theoretically based, using a conceptual model of access to health care, with a focus on illness level (prevalence), enabling factors (the delivery system, organization and financing, the promise of telemedicine), and predisposing factors (special populations, beliefs, mlues, stigma).

The Journal of Rural Health, 2001

This study takes advantage of a "natural experiment" resulting from the reassignment of all Maine... more This study takes advantage of a "natural experiment" resulting from the reassignment of all Maine state eniployees to a managed behavioral health plan in December 1992.

The Journal of Rural Health, 1999

Despite the prevalence and consequence of depression in rural areas, the literature on treating d... more Despite the prevalence and consequence of depression in rural areas, the literature on treating depression in rural areas is relatively scarce and inconclusive. The use of mental health services by rural people sufferingfrom depression and the role that supply may play in explaining these differences are not well understood. Understanding these issues for rural Medicaid beneficiaries is important as Medicaid managed care for physical and behavioral health care is expanded to rural areas. This study compares the mental health service use of rural and urban Medicaid beneficiaries, ages 18 to 64, in Maine sufferingfrom depression and examines what influence mental health and primary care supply have in explaining observed differences. Two models are used to estimate the use of ambulatory mental health services: (1) a logit likelihood estimate of whether a beneficiary uses any outpatient mental health services for depression; (2) an ordinary least squares regression estimating the number of annualized ambulatory mental health care visits among users. Rural beneficiaries suffering from depression have lower utilization than urban beneficiaries. Rural and urban Aid for Families with Dependent Children (AFDC)-and Supplemental Security Income (SSU-beneficiaries suffering from depression rely more on mental health than on general health care providers to receive arnbulato ry mental health care. Rural beneficiaries (AFDC and SSI) rely relatively more on general health care providers than urban beneficiaries. Multivariate analysis suggests that mental health supply and patient-level factors, but not primary care supply, account for utilization differences. This article describes the need to better understand factors limiting participation of prima ry care providers and to study the role of supply across multiple states.

The Journal of Rural Health, 2003

Context: Very little is known about the health care safety net in small towns, especially in town... more Context: Very little is known about the health care safety net in small towns, especially in towns where there is no publicly subsidized safely-net health care. Purpose: This pilot study of the primary care safety net in 7 such communities was conducted to start building knowledge about the rural safety net. Met conducted and seconda y data collected to assess the terviews were people in these comm needed access to afor lthough the ]percentage of rural residents without health insurance is at least as high as the national percentage,' very little is known about rural safety-net

The Journal of Rural Health, 2003

rural areas The fourth section describes the results of the inventory The fifth section reviews t... more rural areas The fourth section describes the results of the inventory The fifth section reviews the evidence to date of the impact of MMBH programs on access to and coordination of rural mental health services The last section discusses current issues for states developing and implementing MMBH in rural areas

The Journal of Rural Health, 2007

H istorical shortages of specialty mental health (MH) practitioners persist in most rural areas o... more H istorical shortages of specialty mental health (MH) practitioners persist in most rural areas of the United States. Approximately three fourths of the MH professions shortage areas in the nation are in rural areas. Studies have shown that lower utilization of MH services is associated with lower provider to population ratios. 2 Problems with access to MH services in rural areas are exacerbated by the disproportionate number of rural, particularly remote rural, residents who are uninsured. 3 Additionally, the safety net role of community MH centers has diminished as their ability to serve the uninsured depends on their ability to cross-subsidize such services with funds designated for their priority populations, those with more serious mental illness. 4 Insured rural residents are less likely to have MH coverage than urban insured populations or face such high coinsurance that they are effectively uninsured for outpatient MH services. 5 Thus, rural residents with MH problems that impair their ability to function, or those with suicidal ideation, may fi nd their way to the hospital emergency room (ER).

Obesity Surgery, Jan 6, 2010

Morbid obesity is associated with serious health and social consequences, high medical costs and ... more Morbid obesity is associated with serious health and social consequences, high medical costs and is increasing in the USA, particularly among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long-term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, insurance categories, socioeconomic, and comorbidity levels. We examined 159,116 records representing 774,000 patients with morbid obesity from the 2006 Nationwide Inpatient Sample. We determined the likelihood, expressed in odds ratios, of bariatric surgery associated with each patient characteristic using survey-weighted univariate logistic regression. We also performed multivariate logistic regression, assuming all patient factors were independent. After adjusting for patient-level characteristics, the most rural residents were 23% less likely to receive bariatric surgery than urban residents. Other demographic features associated with significantly lower odds ratios for bariatric surgery included minority status, male gender, lower income, older age, non-private insurance status, and higher comorbidity. Rural-dwelling patients who are non-white, male, poorer, older, sicker, and non-privately insured almost never received bariatric surgery (OR = 0.0089). Though obesity is more prevalent among middle-aged, rural, economically disadvantaged, and racial/ethnic minority populations, these patients are unlikely to access bariatric surgery. Because obesity is a leading cause of preventable morbidity and mortality in the USA, effective treatments should be made available to all patients who might benefit. Current Medicare/Medicaid policies that reimburse only high volume centers may effectively deny rural residents who rely on these insurance programs for bariatric surgery.

American Journal of Public Health, Jun 1, 1992

Childhood Obesity, 2011

Abstract Background: the food environment, including access to retail food outlets and the presen... more Abstract Background: the food environment, including access to retail food outlets and the presence of healthy food in the home, has been shown to be associated with eating behavior and obesity, but this relationship is not well understood in rural locations. ...

Rural and Remote Health, 2011

Childhood obesity rates appear to be more pronounced among youth in rural areas of the USA. The a... more 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. 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. 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'. 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.

Psychiatric Services, Oct 7, 2014

Linking primary care with psychiatric care has long been promoted as a way to improve access to r... more Linking primary care with psychiatric care has long been promoted as a way to improve access to rural mental health services. The authors describe a national survey that identified 53 successfully linked programs, ranging from small local efforts to sophisticated multicounty networks. Findings indicated that lessons from successful integrations are not easily reduced to a how-to list. Organizations cooperate with each other when it is in their interests to do so. Motivation to integrate cannot be mandated, nor is the availability of funding alone sufficient to provide motivation. The authors discuss ways that managed care may facilitate or hinder the link between rural primary care and rural psychiatry.

This book provides a summary and background of the current state of rural mental health and speci... more This book provides a summary and background of the current state of rural mental health and special consideration in working with rural populations. Chapters discuss some of the major models of service delivery that have been developed to address specific challenges faced in the delivery of quality mental health services. Finally, the book examines specific considerations and best practices for working with distinct subgroups in rural areas, ranging from minority groups to veterans. The book concludes with a discussion on the next steps in advancing the mental health of rural groups. This chapter on Substance Use and Abuse in Rural America looks at the prevalence of substance use and abuse in rural areas compared with urban, efforts to prevent substance use and abuse, treatment availability and accessibility, and continuing care and long-term support for abstinence. It also presents models of service delivery that address resource limitations common to rural areas.

Administration and policy in mental health, 1998

This paper presents findings from a study designed to identify and describe models for integratin... more This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models--diversification, linkage, referral and enhancement--which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.

Current Obesity Reports, 2015

Within most developed countries, rural residents are more likely to be obese and overweight compa... more Within most developed countries, rural residents are more likely to be obese and overweight compared to their urban counterparts. Studies of specific rural communities have found that the limited availability of healthy foods in the community and home as well as individual characteristics and preferences contribute to poor diet and overweight. The rural food environment is varied and may be affected by climate, regional and cultural preferences, transportation access, and remoteness among other factors. Given this diversity and the vulnerabilities of rural residents, who are more likely to have low-income, substandard housing or low educational attainment compared to their urban counterparts, policy and programmatic interventions should target specific needs and communities. This review will describe the rural community, home, and individual food environments and what is known about their roles in healthy eating.

Psychiatric Services, 2010

This study investigated inpatient psychiatric units in small rural hospitals to determine their c... more 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. 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. 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). 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.

Obesity Surgery, 2010

Morbid obesity is associated with serious health and social consequences, high medical costs and ... more Morbid obesity is associated with serious health and social consequences, high medical costs and is increasing in the USA, particularly among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long-term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, insurance categories, socioeconomic, and comorbidity levels. We examined 159,116 records representing 774,000 patients with morbid obesity from the 2006 Nationwide Inpatient Sample. We determined the likelihood, expressed in odds ratios, of bariatric surgery associated with each patient characteristic using survey-weighted univariate logistic regression. We also performed multivariate logistic regression, assuming all patient factors were independent. After adjusting for patient-level characteristics, the most rural residents were 23% less likely to receive bariatric surgery than urban residents. Other demographic features associated with significantly lower odds ratios for bariatric surgery included minority status, male gender, lower income, older age, non-private insurance status, and higher comorbidity. Rural-dwelling patients who are non-white, male, poorer, older, sicker, and non-privately insured almost never received bariatric surgery (OR = 0.0089). Though obesity is more prevalent among middle-aged, rural, economically disadvantaged, and racial/ethnic minority populations, these patients are unlikely to access bariatric surgery. Because obesity is a leading cause of preventable morbidity and mortality in the USA, effective treatments should be made available to all patients who might benefit. Current Medicare/Medicaid policies that reimburse only high volume centers may effectively deny rural residents who rely on these insurance programs for bariatric surgery.

The Journal of Rural Health, 2008

Purpose: Addressing substance abuse in rural America requires extending our understanding beyond ... more Purpose: Addressing substance abuse in rural America requires extending our understanding beyond urban-rural comparisons to how substance abuse varies across rural communities of different sizes. We address this gap by examining substance abuse prevalence across 4 geographic levels, focusing on youth (age 12-17 years) and young adults (age 18-25 years). Methods: The analysis is based on 3 years (2002)(2003)(2004) of pooled data from the National Survey on Drug Use and Health. We measure rurality using a four-tier consolidation of the 2003 Rural-Urban Continuum Codes: urban, rural-adjacent, rural-large, and rural-small and medium. Findings: Rural youth have higher alcohol use and methamphetamine use than urban youth and the more rural the area, the higher the use. Rural young adults living in rural-large areas have higher rates of substance abuse than their urban peers; those living in the most rural areas have nearly twice the rate of methamphetamine use as urban young adults. Rural youth are more likely than urban youth to have engaged in the high-risk behavior of driving under the influence of alcohol or other illicit drugs. Conclusions: Higher prevalence rates, coupled with high-risk behavior, place rural youth and young adults at risk of continued substance use and problems associated with this use. Rural community infrastructure should be enhanced to support substance abuse prevention and intervention for these populations.

The Journal of Rural Health, 2009

The Journal of Rural Health, 2002

This article seeks to identify current research priorities in the area of rural behavioral healfh... more This article seeks to identify current research priorities in the area of rural behavioral healfh. The method for accomplishing this task begins by identifying several domains where policy has a potential to effect improzmnents in access or quality but has been hampered by lack of empirical kmledge. In each domain a synthesis of current research summarizes what is known and draws attention to knowledge gaps. Research questions in each domain are proposed. The policy domains are theoretically based, using a conceptual model of access to health care, with a focus on illness level (prevalence), enabling factors (the delivery system, organization and financing, the promise of telemedicine), and predisposing factors (special populations, beliefs, mlues, stigma).

The Journal of Rural Health, 2001

This study takes advantage of a "natural experiment" resulting from the reassignment of all Maine... more This study takes advantage of a "natural experiment" resulting from the reassignment of all Maine state eniployees to a managed behavioral health plan in December 1992.

The Journal of Rural Health, 1999

Despite the prevalence and consequence of depression in rural areas, the literature on treating d... more Despite the prevalence and consequence of depression in rural areas, the literature on treating depression in rural areas is relatively scarce and inconclusive. The use of mental health services by rural people sufferingfrom depression and the role that supply may play in explaining these differences are not well understood. Understanding these issues for rural Medicaid beneficiaries is important as Medicaid managed care for physical and behavioral health care is expanded to rural areas. This study compares the mental health service use of rural and urban Medicaid beneficiaries, ages 18 to 64, in Maine sufferingfrom depression and examines what influence mental health and primary care supply have in explaining observed differences. Two models are used to estimate the use of ambulatory mental health services: (1) a logit likelihood estimate of whether a beneficiary uses any outpatient mental health services for depression; (2) an ordinary least squares regression estimating the number of annualized ambulatory mental health care visits among users. Rural beneficiaries suffering from depression have lower utilization than urban beneficiaries. Rural and urban Aid for Families with Dependent Children (AFDC)-and Supplemental Security Income (SSU-beneficiaries suffering from depression rely more on mental health than on general health care providers to receive arnbulato ry mental health care. Rural beneficiaries (AFDC and SSI) rely relatively more on general health care providers than urban beneficiaries. Multivariate analysis suggests that mental health supply and patient-level factors, but not primary care supply, account for utilization differences. This article describes the need to better understand factors limiting participation of prima ry care providers and to study the role of supply across multiple states.

The Journal of Rural Health, 2003

Context: Very little is known about the health care safety net in small towns, especially in town... more Context: Very little is known about the health care safety net in small towns, especially in towns where there is no publicly subsidized safely-net health care. Purpose: This pilot study of the primary care safety net in 7 such communities was conducted to start building knowledge about the rural safety net. Met conducted and seconda y data collected to assess the terviews were people in these comm needed access to afor lthough the ]percentage of rural residents without health insurance is at least as high as the national percentage,' very little is known about rural safety-net

The Journal of Rural Health, 2003

rural areas The fourth section describes the results of the inventory The fifth section reviews t... more rural areas The fourth section describes the results of the inventory The fifth section reviews the evidence to date of the impact of MMBH programs on access to and coordination of rural mental health services The last section discusses current issues for states developing and implementing MMBH in rural areas

The Journal of Rural Health, 2007

H istorical shortages of specialty mental health (MH) practitioners persist in most rural areas o... more H istorical shortages of specialty mental health (MH) practitioners persist in most rural areas of the United States. Approximately three fourths of the MH professions shortage areas in the nation are in rural areas. Studies have shown that lower utilization of MH services is associated with lower provider to population ratios. 2 Problems with access to MH services in rural areas are exacerbated by the disproportionate number of rural, particularly remote rural, residents who are uninsured. 3 Additionally, the safety net role of community MH centers has diminished as their ability to serve the uninsured depends on their ability to cross-subsidize such services with funds designated for their priority populations, those with more serious mental illness. 4 Insured rural residents are less likely to have MH coverage than urban insured populations or face such high coinsurance that they are effectively uninsured for outpatient MH services. 5 Thus, rural residents with MH problems that impair their ability to function, or those with suicidal ideation, may fi nd their way to the hospital emergency room (ER).