EDUCATIONAL AND COMMUNITY-BASED PROGRAMS IN RURAL AREAS: A LITERATURE REVIEW

by Larry Gamm, Graciela Castillo, and Lisa Williams

SCOPE OF PROBLEM

· Educational and community-based programs was virtually tied for sixth place with four other focus areas as a top rural health priority area.¹

· School, worksite, health facility, and community-based health education, prevention, and intervention programs are able to access large segments of the population; however, these programs may be less prevalent in rural than urban settings.

· According to a 1994 report, only 28 percent of school districts meet the recommended standard of one school nurse per 750 students. School nurses in rural areas are often responsible for schools that are many miles apart.²

· Smaller employers—the mainstay of rural economies—are less likely than larger employers to offer health promotion and disease prevention programs.^3-5

· Rural areas may lack the readiness, resources, and technical expertise necessary to develop successful and sustainable educational and community-based programs.^5-13

GOALS AND OBJECTIVES

The Healthy People 2010 (HP2010) goal for the Educational and Community-Based Programs focus area is to increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and improve health and quality of life.¹⁴ Settings such as the school, worksite, health care facility, and community are an integral part of this goal, supporting and facilitating the delivery of health promotion, prevention, and intervention programs. Each setting provides access to select populations using “existing social structures.” People often have high levels of contact with such settings, both directly and indirectly. This reduces the time and resources necessary for program development and maximizes the impact by reaching large populations repeatedly.¹⁵ Programs that combine several if not all four settings can have a greater impact than those utilizing one setting alone. While populations will sometimes overlap, the most important fact is that people who are not accessible in one setting may be so in another.

The following Healthy People 2010 objectives are addressed in this chapter:

School Setting

• 7.2. School health education

• 7.4. School nurse-to-student ratio

Worksite Setting

• 7.5. Worksite health promotion programs

• 7.6. Participation in employer-sponsored health promotion activities

Health Care Setting

• 7.7. Patient and family education

• 7.9. Health care organization sponsorship of community health promotion activities

Community Setting and Select Populations

• 7.10. Community health promotion programs

• 7.11. Culturally appropriate and linguistically competent community health promotion programs

• 7.12. Older adult participation in community health promotion activities

Pertinent to this discussion is a brief synopsis of the unique role played by each of the four settings in contributing to the health promotion of students, parents, employees, patients, and the community.

School-based programs. Local schools include populations of students who reside within defined school district boundaries. Students’ roles of learning and participating in health and physical education programs as required are central to the schools’ support of healthy students. It is also possible that schools will provide a school nurse and/or invite other health professionals to offer selected health promotion, prevention, and treatment services. The “safety net” role of the school may be particularly important for students who may not be insured or lack a regular provider. Instrumental in this effort is the Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care Healthy Schools/Healthy Communities Program, which offers grant support for school-based health centers targeting underserved and at-risk children (http://bphc.hrsa.gov/HSHC).

Worksite-based programs. At the worksite, employees—insured or not—are important resources for employer success. The employer is dependent on the employees’ good health to avoid both absenteeism and costs of untreated illness or disability. Participation in employee health programs may be promoted as part of continued employment. The effectiveness of such programs may reduce health costs and help maintain cheaper rates for employee health insurance.

Health care organizations. These organizations have a responsibility for the health of their patient populations and for providing physicians, nurses, patient educators, social workers, and staff to serve patients. Patients tend to be dependent on professionals regarding their health status. Health care organizations are viewed as legitimate providers of primary, secondary, and tertiary prevention activities and supporters of patient compliance with treatment regimens or more extensive disease management protocols. Except for those health care organizations that share in risk via capitation or ownership in a health plan, such organizations may not be given financial incentives to engage in education and community-based program activities. Not-for-profit healthcare providers, however, may be expected to offer such activities as part of their legal obligation to their community and/or commitment of professionals to more fully address health conditions through outreach and follow-up of patients beyond the patient visit.

Community-based programs. These programs are designed to reach all residents or particular target subgroups, such as the homeless, or other groups subject to greater risks that are not fully addressed by other providers or parties. Such programs may rely upon mass media or other broad information dissemination strategies. Some of these or other more effective community-wide programs employ partnerships with other organizations and settings like those noted above and/or others such as churches, boys/girls clubs, social service organizations, local government, fraternal organizations, and the like to initiate educational and prevention programs. Similar coalitions or networks can support policy interventions such as those that enact and enforce smoking ordinances in public places or limit tobacco and alcohol sales to minors.

Finally, it should be noted, this review differs somewhat from other Rural Healthy People 2010 literature reviews because it focuses to a greater degree on intervention strategies than upon specific health conditions or provider groups. This review focuses on four settings and associated rural issues—disparities, barriers, and challenges—that are encountered in the setting as well as solutions or interventions feasible in rural areas. The chapter concludes with a review of some evaluation and sustainability issues that should be considered in pursuing education and community-based programs in rural communities.

Identified by people living in rural areas as a high priority health issue for them

Based on our survey of state and local rural health leaders, Educational and Community-Based Programs was virtually tied for sixth place with four other focus areas as a top rural health priority area.¹ Separate treatment of this focus area is justified in terms of its importance to addressing many of the other Healthy People 2010 focus areas. A significant portion of the research literature presented here dovetails with interventions discussed in our literature reviews of other rural health priorities. Similarly, many of our Models for Practice, which have already appeared, offer illustrations of Educational and Community-Based Programs.

This review addresses the importance of channeling education, prevention, and intervention efforts through multiple settings. It examines the various types of populations that are intended to benefit from programs offered in particular settings and/or under different auspices in the community. For each of the four basic settings presented in Healthy People 2010, the review examines the necessity and opportunities for programs, types of programs offered, illnesses or other conditions addressed, weaknesses or barriers to progress, and proposed solutions. Finally, the chapter will review some common challenges and opportunities shared among the four settings: personnel and expertise, leadership, funding, and evaluation.

PREVALENCE AND DISPARITIES IN RURAL AND URBAN AREAS

The issues and disparities facing rural America in the delivery of educational and community-based programs are described in this section by setting (e.g., school, worksite, health care organization, and community).

School-based Setting

An estimated 14.9 million children live in non-metropolitan, rural areas.¹⁹ Approximately 20 percent of all students in public elementary and secondary schools in the United States reside in rural areas.¹⁸

Children who live in rural areas—especially minority children and adolescents—are less likely to be insured than urban children.¹⁹ For these and other school children, a school’s health education programs, and in some instances a school nurse or in rarer situations a school-based health center, may be critically important to the health of rural students.

The rural school is often the most prominent institution in rural areas and may be a logical anchor for health programs.¹⁶ The local school may be one of the largest local employers, the predominant focus of community identity among residents, the leading financial resource, and a major communications hub within a rural community. In addition to affecting students, school-based programs can influence other groups, such as teachers and parents.¹⁷

The school is an effective setting for presenting health promotion and disease prevention programs and for delivering primary care and treatment services for rural children. Several studies that examine the school environment’s effect on children’s health and health-related behavior show school-based approaches can have a powerful influence on the health behaviors of students. Such approaches have been shown to successfully improve health habits while reducing behavior-related risk factors.^25-27 Effective health promotion programs that target children may also have a positive impact on their health care costs even beyond childhood. For example, cardiovascular disease risks and eating behaviors that are established in childhood often carry into adulthood.^20-24

Schools, too, are logical settings for delivering substance abuse programs targeting children and adolescents.²⁸ Such programs, however, may require approaches extending beyond traditional teaching. There is ample evidence that school-based programs emphasizing interactive approaches are more effective than non-interactive; such approaches have been equally successful for tobacco, alcohol, marijuana, and other illicit drugs.⁷⁰ Although most such interventions studied are from urban schools, success has occurred in rural schools as well.⁷¹ For example, an experiment targeting 36 rural schools in Midwestern communities found that classroom-based life skills training (LST) combined with efforts to strengthen families consistently demonstrated a lower alcohol new-user rate than did those schools that used LST alone or that did neither intervention.⁷² A study of interventions in nearly 100 schools found they worked nearly equally well in rural, suburban, and urban schools.⁷³

School-based health centers (SBHCs) are generally viewed as offering access to comprehensive physical and mental health services to school children.²⁹ Although relatively few of the over 90,000 public elementary and secondary schools have school-based health centers, there are an estimated 1,400 school-based health centers in the country. A nationwide survey in 2002 found 28 percent of school-based health centers were located in rural areas, in contrast to 61 percent in urban and 12 percent in suburban areas. Only seven states reported no school-based health centers: Arkansas, Hawaii, Idaho, Montana, North Dakota, South Dakota, and Wyoming.²⁹

An assessment of school-based health centers in West Virginia showed that enrollment rates in SBHCs in rural schools were significantly higher than in urban schools—86 percent and 46 percent, respectively. High utilization rates by both uninsured students and students covered by Medicaid were also found—26 percent of the uninsured and 26 percent of Medicaid. Rural school-based health centers have the potential to reach vulnerable populations where access to preventive and primary care services are inadequate.³⁰

Although there can be a strong argument for school-based health centers, it is important to assess a community’s perception of having a school-based health center in the planning stages and also in the evaluation stage.⁷⁴ An assessment can evaluate the “acceptability” of a center as well as the type of services that are perceived as needed. The input of community leaders, businesses, parents of school-aged children, school administrators, health providers, school staff, and students is important.⁷⁴

School nurses have been credited historically for initiating health education and screenings in rural schools.³¹ These nurses provide various services to students and occasionally to staff and parents. Services provided include health education, screenings and assessments, referrals, medications, and the supervision of students with chronic diseases. The majority of school nurses (more than 90 percent) monitor students with chronic conditions such as diabetes or asthma.³² Recent state funding cutbacks, however, have reduced local school funding for school nurses, counselors, tutors, and other support personnel.⁷⁵ According to a 1994 report, only 28 percent of school districts meet the recommended standard of one school nurse per 750 students. Furthermore, school nurses in rural areas are often responsible for schools that are many miles apart.³² Among schools averaging 190 students per school, over 40 percent of the respondents said their school had no services from a school nurse, and only 2 percent reported having school nurse services 40 hours a week.⁷

As a result of this shortage, it is not uncommon for school secretaries to assume many of the school nurse functions in the absence of a school nurse in some rural schools. A recent survey of school secretaries in Montana local schools found that among the 61 percent responding, nearly three-quarters of these non-health professionals do, in fact, provide care for injuries or illnesses on a weekly basis. Although lacking formal training in support of the health activities they provide, the school secretaries felt generally confident in dealing with injuries, taking temperatures, and handing out medications, among other activities. Approximately 70 percent of the surveyed school secretaries passed out prescription medication on a weekly basis, with about one-half talking to parents just as frequently regarding the health of their child.

Given the increased reliance of children on medications, the American Academy of Pediatrics issued a policy statement to guide school policymakers and to state their concerns about schools’ reliance on untrained personnel in addressing children’s health care needs. In the absence of state laws or regulations on this matter, school officials should seek legal advice on medication administration by non-professionals, student confidentiality, storage of medications, and related issues.⁷⁶

One would imagine that in such schools there is also a minimum provision of health education or psychological counseling expertise. A 2003 report on the state of Washington’s children noted that rural school districts, in contrast to urban and suburban districts, have limited or no access to school nurses and psychologists.³³ Rural school counselors are less likely to be licensed professional counselors and less likely, also, to be active in professional associations. Counselors usually identify financial resources and staff support as being the greatest needs.⁶

Typically, school counselors are among a loose network of physicians, school counselors, mental health workers, and child protective caseworkers who serve rural children with mild mental health problems.^77-79 Schools may have become the de facto mental health provider for the largest proportion of rural children receiving services.⁷⁷ There is some evidence that an aging school psychologist supply will further undermine the ability of schools to meet these needs.⁸⁰

Worksite Settings

Worksites are an important setting for targeting health improvement among adults. The majority of workers are insured through employer-purchased insurance; thus, preventing illness may reduce insurance costs. Worksite prevention and health promotion can reduce illnesses and injuries that otherwise may decrease productivity, increase absenteeism, and reduce employers’ profits.³⁷ Worksite health promotion and disease prevention programs can include all or a combination of several elements such as health education, physical fitness and nutrition, health services a