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PURPOSE: To estimate percent excess deaths during the COVID-19 pandemic by rural-urban residence in the United States and to describe rural-urban disparities by age, sex, and race/ethnicity. METHODS: Using US mortality data, we used overdispersed Poisson regression models to estimate monthly expected death counts by rurality of residence, age group, sex, and race/ethnicity, and compared expected death counts with observed deaths. We then summarized excess deaths over 6 6-month time periods. FINDINGS: There were 16.9% (95% confidence interval [CI]: 16.8, 17.0) more deaths than expected between March 2020 and February 2023. The percent excess varied by rurality (large central metro: 18.2% [18.1, 18.4], large fringe metro: 15.6% [15.5, 15.8], medium metro: 18.1% [18.0, 18.3], small metro: 15.5% [15.3, 15.7], micropolitan rural: 16.3% [16.1, 16.5], and noncore rural: 15.8% [15.6, 16.1]). The percent excess deaths were 20.2% (20.1, 20.3) for males and 13.6% (13.5, 13.7) for females, and highest for Hispanic persons (49% [49.0, 49.6]), followed by non-Hispanic Black persons (28% [27.5, 27.9]) and non-Hispanic White persons (12% [11.6, 11.8]). The 6-month time periods with the highest percent excess deaths for large central metro areas were March 2020-August 2020 and September 2020-February 2021; for all other areas, these time periods were September 2020-February 2021 and September 2021-February 2022. CONCLUSION: Percent excess deaths varied by rurality, age group, sex, race/ethnicity, and time period. Monitoring excess deaths by rurality may be useful in assessing the impact of the pandemic over time, as rural-urban patterns appear to differ.

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Paid sick leave (PSL) is associated with health care access and health outcomes. The COVID-19 pandemic highlighted the importance of PSL as a public health strategy, yet PSL is not guaranteed in the United States. Rural workers may have more limited PSL, but research on rural PSL has been limited. We estimated unadjusted and adjusted PSL prevalence among rural versus urban workers and identified characteristics of rural workers with lower PSL access using the 2014-2017 Medical Expenditure Panel Survey. We found rural workers had lower access to PSL than urban workers, even after adjusting for worker and employment characteristics. Paid sick leave access was lowest among rural workers who were Hispanic, lacked employer-sponsored insurance, and reported poorer health status. Lower rural access to PSL poses a threat to the health and health care access of rural workers and has implications for the COVID-19 public health emergency and beyond.

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PURPOSE: Electronic health records (EHRs) can facilitate primary care providers' (PCPs) use of best practices in addressing tobacco dependence. It is unknown whether rural PCPs reap the same benefits as their urban counterparts when employing EHRs for this purpose. Our study examines this issue. METHODS: This cross-sectional investigation based on the 2012-2015 National Ambulatory Medical Care Survey used chi-square tests and adjusted logistic regression models to explore how rurality and use of tobacco-related EHR functions were related to smoking status documentation (SSD) and cessation treatment at adult primary care visits. FINDINGS: SSD rates were similar in visits to rural- and urban-based PCPs (88.2% rural-based vs 81.1% urban-based, P = .5819). Use of EHRs for SSD was associated with higher SSD odds at visits to both rural- and urban-based PCPs, but this increase was greater for visits to rural-based PCPs (428% vs 220% urban-based, P = .0443). Rates of cessation treatment at smokers' visits were low in rural and urban contexts (19.3% rural vs 19.6% urban, P = .9430). Odds of cessation treatment were 68% higher where EHRs were used to remind PCPs of treatment guidelines (P = .001), with no rural-urban difference in the size of the increase. Access to EHRs with tobacco-related functions was similar across rural and urban practices. CONCLUSIONS: Rural-based PCPs were at least as successful as urban-based PCPs in leveraging EHRs to enhance tobacco-related services. Even where EHRs are used, opportunities exist to expand cessation treatment in rural primary care.

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OBJECTIVE: To estimate differences in emergency contraception (EC) use, access, and counseling by rural-urban residence among reproductive age women in the United States. STUDY DESIGN: We examined respondent data (2006-2017) from the National Survey of Family Growth for women ages 15-44 (n = 28,448) to estimate EC use, access, and counseling by rural-urban county of residence. Rural-urban prevalence ratios for EC outcome measures were estimated using predicted margins from logistic regression models, which were adjusted for demographic differences and current contraceptive method use. Changes in ever-use of EC over time were estimated for rural and urban respondents, separately, using Chi-square tests and trends were estimated using inverse variance weighted linear regression models. RESULTS: During 2006 to 2017, 10% of rural and 19% of urban women who had ever had sex reported ever using EC pills. Among rural women, ever-use increased from 6% in 2006-2008 to 15% in 2015-2017 (Chi-square p < 0.01; trend p-value < 0.01); among urban women, ever-use increased from 11% to 27% (Chi-square p < 0.01; trend p-value < 0.01). Rural and urban women were similarly likely to have obtained EC without a prescription and from a drug store. Rural women were less likely to have received EC counseling than urban women; however, counseling rates were low among all women. CONCLUSION: We observed differences in EC ever-use and receipt of EC counseling by rural-urban residence among US women ages 15 to 44, adding to the evidence that rural-urban residence is an important factor in reproductive health. More research is needed to explore factors contributing to rural-urban differences in EC use. IMPLICATIONS: Our key finding that EC use varied by rural-urban county residence offers additional evidence that rural-urban residence should be considered in reproductive health practice and policy. We discuss areas for future research into potential barriers to EC use in rural populations.

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The US public health community has demonstrated increasing awareness of rural health disparities in the past several years. Although current interest is high, the topic is not new, and some of the earliest public health literature includes reports on infectious disease and sanitation in rural places. Continuing through the first third of the 20th century, dozens of articles documented rural disparities in infant and maternal mortality, sanitation and water safety, health care access, and among Black, Indigenous, and People of Color communities. Current rural research reveals similar challenges, and strategies suggested for addressing rural-urban health disparities 100 years ago resonate today. This article examines rural public health literature from a century ago and its connections to contemporary rural health disparities. We describe parallels between current and historical rural public health challenges and discuss how strategies proposed in the early 20th century may inform current policy and practice. As we explore the new frontier of rural public health, it is critical to consider enduring rural challenges and how to ensure that proposed solutions translate into actual health improvements. (Am J Public Health. 2020;110:1678-1686. https://doi.org/10.2105/AJPH.2020.305868).

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