EDUCATIONAL AND COMMUNITY-BASED PROGRAMS IN RURAL AREAS

by Larry Gamm, Graciela Castillo, and Lisa Williams

 

 

SCOPE OF PROBLEM

 

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

·       School, worksite, health facility, and community-based health promotion, prevention and intervention programs reach 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 community and education-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; each setting provides access to select populations through existing organizational and social structures.15 Programs combining any or all four settings can have a greater impact than those utilizing one setting alone. This reduces the time and resources necessary for program development and maximizes the impact by reaching large populations repeatedly.15

 

The following Healthy People 2010 objectives are addressed:

 

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 health promotion programs

·       7.12. Older adult participation in community health promotion activities

 

Based on a survey of state and local rural health leaders, the Educational and Community-Based Programs focus area was virtually tied for sixth place with four other areas as a top rural health priority area.1

 

This overview differs from most others in Rural Healthy People 2010 since it does not focus upon specific health conditions or provider groups. Instead, the focus is on the health education and prevention strategies used in different settings and the rural issues—disparities, barriers, and challenges—encountered as well as evaluation, sustainability, and feasible solutions/interventions in rural areas.

 

PREVALENCE

 

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

 

School-based Setting

 

A rural school is often the most prominent institution and one of the largest local employers in the area. School-based programs can influence students, teachers, and parents.16, 17 Approximately 20 percent of all students in public elementary and secondary schools in the United States reside in rural areas.18 Children living in rural areas, especially minority children and adolescents, are less likely to be insured than urban children.19 For these and other school children, school health education programs, school nurses, and school-based health centers may be vitally important to their health.

 

Health promotion programs for children are effective and may impact child health beyond childhood. For example, cardiovascular disease risks and eating behaviors established in childhood often carry into adulthood.20-24 School-based approaches can improve health habits while reducing behavior-related risk factors.25-27 Additionally, studies of school-based tobacco and substance abuse program interventions have been found to be effective.26, 28 Such interventions have been found to be nearly equal in effectiveness across rural, suburban, and urban schools.26

 

School-based health centers (SBHCs) may provide comprehensive physical and mental health services to students.29 Of an estimated 1,400 school-based health centers across the U.S. in 2002, 28 percent are located in rural areas in contrast to 61 percent in urban and 12 percent in suburban areas. A study of West Virginia centers found higher enrollment rates in rural SBHCs than in urban schools—86 percent and 46 percent, respectively.30

 

Rural school nurses play a significant role in the health-related activities of schools.31 They provide services such as health education, screenings and assessments, and medications. In addition, more than 90 percent of school nurses monitor students with chronic conditions such as diabetes or asthma.32 However, a 1994 report found only 28 percent of school districts meet the recommended standard of one school nurse per 750 students. Among schools with an average of 190 students, over 40 percent of schools responding to the survey did not have a school nurse.7

 

A school nurse shortage may reduce both the amount and quality of health promotion and prevention activities. A 2003 Washington state report noted rural school districts have limited or no access to school nurses and psychologists.33 To make matters worse, school nurses in rural areas are often responsible for schools that are many miles apart.32 This shortage may force other school staff members, such as secretaries, to assume school nurse functions in some rural schools. A Montana survey of school secretaries found nearly three-quarters of respondents provided care for students’ injuries or illnesses on a weekly basis, while 70 percent of respondents passed out prescription medication on a weekly basis.7

 

Worksite Settings

 

Worksite health programs vary from health education, services and benefits, and counseling programs to policies that promote safe working conditions.34, 35 These programs have been found to reduce medical care costs and absenteeism.36, 37 Most worksite studies of health promotion activities, however, focus on large businesses,5, 36 while rural economies are relatively more reliant on small businesses.5

 

According to 2002 survey of Georgia employers, smaller employers are less likely than larger employers to offer at least one health promotion and disease prevention program—68 percent versus approximately 90 percent, respectively. Although nearly as likely as large employers to have smoking restrictions, small employers are less likely to have programs for physical activity, nutrition and weight management, or disease management.3, 4

 

Several reasons are frequently cited for the few health promotion programs in small businesses. These include: (1) lack of a knowledgeable staff member able to design and organize a health program; (2) financial inability to offer health insurance and promotion and preventive programs; and, (3) burden of health and safety regulations that may limit resources for those programs not required by law.5

 

Health Care Facility Settings

 

Health care facilities are frequent settings for health promotion, prevention, and treatment programs. Health providers are often trusted and respected, and patients are usually receptive to health information they provide.15 In physician offices, prevention education for patients is viewed as part of the physician’s role, and evaluations of the effectiveness of these efforts are published.38

 

Several rural community health centers have participated in the U.S. Bureau of Primary Health Care-sponsored collaboratives that have focused on secondary and tertiary prevention of chronic illnesses since 1998. Although patients relying on such centers are more likely to be poor and uninsured or on Medicaid, there is evidence rural health center patients are significantly more likely than people in the general rural population to receive preventive services and experience decreased rates of low birth weight, especially among African Americans.39, 40

 

Hospitals have a history of health promotion and disease prevention activities in the community. A survey of Iowa hospitals found over 98 percent of rural hospitals offered health promotion services such as cancer screenings, safety and protection programs, nutrition programs, and prenatal/maternal health services.41 Rural hospitals frequently collaborate with providers and community organizations such as churches, civic clubs, and employers to pool resources to fund and staff programs and services for larger populations. In general, hospital collaboration with community organizations can be associated with desires to improve the community health and/or any of several threats—external regulation, loss of tax exempt status for nonprofit hospitals, or increased market competition.8, 42

 

Community Settings

 

Community-based programs seek to improve a community’s health through comprehensive approaches combining education, prevention, screening, and treatment.43 Such approaches can effectively reach special populations who are otherwise difficult to reach—rural, undereducated, economically disadvantaged, or minority groups.26

 

A community health governance model developed by a workgroup of nine partnerships in Turning Point, a foundation-funded initiative, emphasizes the importance of collaborations to empower individuals within communities, to bridge social ties in the community, and to create and leverage synergy.12 Community-based programs require a diverse group of members representing a cross-section of social and economic sectors of the community. Community involvement is necessary at all stages—assessing needs, identifying resources, and implementing and governing the program. This ensures that the multiple factors affecting the health of a population are considered and incorporated into interventions.44-47

 

BARRIERS

 

Effective Mobilization

 

It is frequently a challenge to mobilize schools, worksites, health facilities, and communities in rural areas. Under-funded schools may be unable to support a school nurse, much less underwrite a school health center. Rural hospitals may not be encouraged by staff or board members to engage in health promotion or disease prevention strategies.8 Even where interest is present, such health care facilities often face time or financial constraints.