Rural Health Inequities

Transcription

1 Rural Health Inequities Michael Meit, MA, MPH Co-Director NORC Walsh Center for Rural Health Analysis 1

2 History of Rural Public Health Governmental PH in the US began in the late 1700s as an urban phenomenon driven by infectious diseases (Yellow Fever) and sanitation concerns. Little concern with rural issues as country living is equated with clean and healthy. 2 2

3 History of Rural Public Health In the late 1890s a zoologist, Charles Stiles, became convinced that hookworm was widespread throughout the South. It is fiction to assume that the country districts are naturally so healthy that there is no need for laws to prevent disease Pennsylvania Governor Daniel Hastings in 1899 Marine Health Service begins to notice a rural/urban connection in many Typhoid Fever cases. 3 3

4 History of Rural Public Health County Health Departments began to develop in response to growing interaction between urban and rural areas Jefferson County, KY (1908); Guilford County, NC (1911); and Yakima County, WA (1911) developed to expand efforts of urban health departments into their rural environs Robeson County, NC first truly rural county health department, established in

5 History of Rural Public Health Rapid expansion of rural health departments thanks to foundation support Rockefeller Fdtn ( ): Sanitary Commission to Eliminate Hookworm Disease; starting in 1916 Commission begins to contribute directly to health dept budgets Milbank Memorial Fund (1922): Cattaraugus County (NY) Demonstration Commonwealth Fund (1924): Rutherford County (TN) Children s Demonstration Children s Fund of Michigan (late 1920s) W.K. Kellogg Foundation (1931) 5 5

6 Rapid Rise of County LHDs Number of County Public Health Units: 1908 to Yet, in 1929 it was estimated that 77% of rural Americans still lacked access to public health services. 6 6

7 What Happened to Rural Public Health? In the 1930s new sources of funding became available with the passage of New Deal programs, leading to significant expansion and reorganization of state public health systems. In the early 1940s funding was diverted to war preparations. In the mid-1940s focus shifted away from infectious diseases and sanitation and to health care access. 7 7

8 Definitions What is rural? Rural: Multiple definitions: By county By Census tract By ZIP Code Multiple grades of rural Micropolitan Frontier Federal government uses 74 definitions of rural, including 16 primary definitions Approximately 20% of residents live in rural areas 8

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10 Social Determinants of Rural Health Socio-economic determinants Poverty and education Economics Psychosocial risk factors Culture Isolation Community and societal characteristics Rural attitudes and culture Access to healthcare and public health services 10

11 Socio-economic determinants Rural residents tend to be poorer than urban residents Per capita income is $9,829 less for rural (2009) 31% of food stamp beneficiaries are rural (approximately 20% of population is rural) 48 of the 50 counties with the highest child-poverty rates are in rural America (2005) Rural residents educational attainment 13.8% have < high school education 19.5% have a bachelor s degree (28.8% urban) 11

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13 Unique Rural Populations - Regional 13

14 Unique Rural Populations Race and Ethnicity Hispanic population in rural areas has been growing faster than any other rural population since 1990s Large rural African American population in Southern and Delta states Large Tribal populations in Plains and Southwestern states 14

15 Unique Rural Populations - Migrant Indiana, Oklahoma, Alabama, and New Mexico had the largest % gains ( ) North Carolina, Florida, Georgia and Texas had the largest # increase ( ) Immigration accounted for 31% of population increase in rural counties ( ) 15

16 Rural Disparities

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18 Source: Rural America at a Glance, 2008 edition, ERS/USDA. 18

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20 Self-Reported Health Status National Health Interview Survey % with Fair or Poor Health (5 point scale) 14 Survey redesign MSA non-msa 20

21 Presence of Chronic Conditions National Medical Expenditure Survey / Medical Expenditure Panel Survey % with Condition Any Chronic Condition Hypertension Arthritis Diabetes Cardiovascular Disease 1987, MSA 1987, non-msa 2004, MSA 2004, non-msa 21

22 Residence and race both linked to disparity Percent of individuals age when interviewed who had died by 2006, by county of residence ( National Health Interview Survey Linked Mortality File) Probst et al, Health Affairs

23 Evidence from Mid-to-Late 1990s Health U.S. 2001, Urban and Rural Health Chart Book Non-metro counties, especially those without a city of 10,000, had higher rates of: Cigarette smoking (adolescents and adults) Obesity (especially for women) Overall death rates (children, young adults, elderly) Death rates from COPD (men) Death rates from unintentional injuries and MVAs Suicides (men) Health related limitation of activity Total tooth loss among the elderly 23

24 Strengthening the Rural Public Health Infrastructure No citizen from any community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection, which is possible only through a local component of the public health delivery system. IOM, 1988

25 Limited resources result in lower staffing levels; recruitment and retention more difficult Funding relies more heavily on state taxes making spending less responsive to local needs Many rural communities have NO local PH infrastructure Less technological capacity to receive health alerts and public health information 25

26 Findings: 50 State Analysis LHD Revenues by Degree of Rurality Rural Micropolitan Urban Local State direct Federal pass-through Federal direct Clinical Meit, Ettaro, Hamlin & Piya, Rural Public Health Financing,

27 Challenges Maintaining PH Infrastructure State budget cuts Limited availability of local funding Limited resident support Fear of taxes Misconceptions about PH Culture of privacy and self-reliance Mixed political support Local governments are generally supportive but reluctant to provide funding for PH State legislatures and gubernatorial support varies and is subject to change Misconceptions about PH among policy makers Meit, Hernandez & Kronstadt, Establishing and Maintaining Rural Public Health Infrastructure,

28 How do we tip the scale? Health protection safety health status Emergency response Unknown benefit taxes government Meit, Hernandez & Kronstadt, Establishing and Maintaining Rural Public Health Infrastructure,

29 Recommendations 1. Combined state-driven and grassroots approaches 2. Develop consistent and compelling public health messages 3. Workforce training and capacity building 4. Regional approaches Meit, Hernandez & Kronstadt, Establishing and Maintaining Rural Public Health Infrastructure,

30 Inconsistency of Federal Funding Funds have been so inadequate and so uncertain as to amount that long term planning has not been practicable. The need of a substantial, consistent, long-term program of Federal support for the rural health service is recognized by practically all authorities in the public health field 1936 PHS Report 30

31 Cattaraugus County, NY Demonstration Conclusion of the Demonstration: It has been shown conclusively that it is possible and practicable to establish a health department in a rural county in New York State and that such a health department can furnish an effective health services for those living in the county. It has been shown also that county authorities are sufficiently interested in such a service to give it substantial financial support, thus ensuring the continuation of the work (Mr. John Walrath, County Board of Health, 1927) 31

32 Promising Rural Approaches Network Activities allow community organizations to pool resources, creating efficiencies in the delivery of services, while enhancing access to services for rural residents. Health Commons Approach In New Mexico oral health stakeholders developed an enhanced, community-based, primary care safety net practice that includes medical, behavioral, social, public and oral health services. Resources were pooled from both private and public sources to support implementation. 32

33 Promising Rural Approaches Rural East TX Behavioral Health Care Network Developed network of CMHC, Critical Access Hospital, SF Austin State Univ School of Social Work, and providers. Established Psychiatric Mental Health Emergency Center with telehealth assessment and triage program. Efforts have expanded to emergency rooms to provide psych assessment and triage, including SA assessment. North Central Iowa Regional Health Coalition Comprised of 18 community action agencies, health system, LHDs, substance abuse and mental health centers. Increased access to youth mental health screening, dental care; scope expanded to address diabetes and childhood obesity. 33

34 Promising Rural Approaches Arizona Rural Women s Health Network Comprised of FQHCs, the SHD, 15 LHDs, AHEC, and community NGOs. Focused on tribal and border women s health issues; worked with state to collect and report on rural women s data (including rural/urban comparisons), created on-line directory of health resources for women. Maine Workforce Network Development Project Large teaching hospital networked with 4 rural hospitals to provide rural practice opportunities for medical students. Designed to not only encourage medical students into rural practice, but also engages students within the rural communities through required community projects, many of which focus on health education. 34

35 Promising Rural Approaches Rural Health Network Funding Opportunities Network Development Planning Program (HRSA ORHP) Rural Health Network Development Program (HRSA ORHP) Delta States Rural Health Network Program (HRSA ORHP) Workforce Network Development Program (HRSA ORHP) HIT Network Development Program (HRSA ORHP) Community Transformation Grant Program (CDC) Leona Helmsley Charitable Trust 35

36 Challenges to Network Formation Study conducted as part of NORC/UMRHRC Rural Health Outreach and Tracking Project for HRSA Office of Rural Health Policy Network Planning Grant Awards N=107 89% Response rate 95/107 83% survival rate 79/95 36

37 Key Challenges to Network Formation Member and community buy-in Identifying collaborative & prioritizing projects Meeting logistics Implementing network strategies Member competitiveness and mistrust 37

38 Important Lessons Learned Be proactive seek opportunities to build value Build support with members that have time and resources to form core group Experienced leadership employed by network Be flexible and open to new ideas Use multiple communication strategies to keep members informed 38

39 Network Post-Grant Sustainability % of surviving networks obtained some form of post-grant funding Prominent funding sources 50% Federal grants 45% Member financial contributions 30% Foundation and private grants 29% Service fees 27% State grants/contracts 21% Member dues 39

40 Network Successes Expansion of Service Capacity (30%) Improving Service Coordination (25%) Maintaining Viable Services (19%) Sharing Resources (16%) Advocating for Rural Health (10%) 40

41 Most Effective Strategies for Post-Grant Survival Employ experienced leadership Start early - Build on efforts Link with organizations that have financial expertise and potential for support Develop a well-conceived business plan Instill value in membership and value in effort Keep planning and operations transparent Governance structure to lend legitimacy and authority to network existence 41

42 Evidence Based Toolkits Toolkits are being developed as part of NORC s OHRP-funded Rural Health Outreach and Tracking Project Community Health Workers Obesity Prevention Mental Health Oral Health 42

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48 Michael Meit, MA, MPH 4350 East West Hwy, Suite 800 Bethesda, MD Thank You!