Rural Public Health Infrastructure: A Literature Review

by Barbara Quiram, Michael Meit, Kay Carpender, Cara Pennel, Graciella Castillo, and Delia Duchicela

 

SCOPE OF PROBLEM

 

·       A majority (69 percent) of local public health agencies serve jurisdictions of less than 50,000 people.1

·       Public health infrastructure was identified as the 12th highest ranking rural health concern in a survey of rural stakeholders.2

·       Web capacity, an important tool in monitoring the health of the community and providing training to public health personnel, is less accessible in health agencies serving populations less than 25,000.3

·       Retaining and recruiting qualified public health professionals to serve in rural areas present barriers to strengthening the rural public health workforce.4

·       While public health nurses provide the majority of care in rural areas, most rural public health nurses were trained in a two-year associate degree program that did not offer public health content within the curriculum.5

·       More non-metropolitan (41 percent) than metropolitan (26 percent) local public health agencies noted funding was their main challenge.1

 

GOALS AND OBJECTIVES

 

The Healthy People 2010 goal for public health infrastructure is to ensure that federal, tribal, state, and local health agencies have the infrastructure to effectively provide essential public health services.6 To strengthen the public health infrastructure in rural areas, it is important to examine specific differences between public health infrastructure in rural communities and their urban counterparts. This literature review addresses the following four areas and related objectives:

 

Data and Information Systems

·       23.1. Public health employee access to the Internet.

·       23.2. Public access to information and surveillance data.

 

Workforce

·       23.8. Competencies for public health workers.

·       23.9. Training in essential public health services.

·       23.10. Continuing education and training by public health agencies.

 

Public Health Organizations

·       23.11. Performance standards for essential public health services.

·       23.12. Health improvement plans.

·       23.13. Access to public health laboratory services.

·       23.14. Access to epidemiology services.

·       23.15. Model statutes related to essential public health services.

 

Resources

·       23.16. Data on public health expenditures.

 

IDENTIFIED BY PEOPLE LIVING IN RURAL AREAS AS A HIGH PRIORITY HEALTH ISSUE FOR THEM

 

In a survey of state and local rural health leaders, public health infrastructure was identified as the 12th highest ranking rural health concern, virtually tying with cancer and nutrition and overweight for the 10th place rank.2  Choosing from among the 28 Healthy People 2010 focus areas, state agencies and state rural and primary care associations, in contrast to rural hospital and rural health center/clinic administrators, were particularly likely to assign high priority rankings to public health infrastructure. All four geographic regions were consistent in ranking public health infrastructure in the 9 to 11 range.

 

PREVALENCE AND DISPARITIES IN RURAL AREAS

 

The goal of the Healthy People 2010 focus area on Public Health Infrastructure is to ensure that federal, tribal, state, and local health agencies have the infrastructure to effectively provide essential public health services.6 The literature reveals a number of alternative definitions for the term “public health infrastructure”; however, most include some reference to the size and training of the public health workforce and systems for communication within the local public health structure and with other entities.4 These are among the elements examined in this literature review to assess the differences between public health infrastructure in rural communities and their urban counterparts.

 

A study of local public health agencies conducted by the National Association of County and City Health Officials (NACCHO) reports that 69 percent of local public health agencies (LPHAs) serve jurisdictions with populations less than 50,000, and half of all agencies serve jurisdictions with populations less than 25,000. In contrast, only 4 percent of all LPHAs serve large metropolitan areas with populations over 500,000.1 The most recent NACCHO study using Rural Urban Commuting Area Codes (RUCAs) classified 48 percent of LPHAs as rural.33

 

Rural local health departments are difficult to enumerate.34 Moreover, all communities are not part of a local public health system. These communities are likely to be disproportionately, if not exclusively, rural and face serious problems of access to public health services. To examine these disparities, this review addresses four areas of potential concern to rural communities with respect to public health infrastructure: data and information systems, workforce, public health organizations, and resources.

 

Data and Information Systems

 

An important element of public health infrastructure is the ability of local health departments to assess and monitor the health of their community, to disseminate timely information, and to identify emerging threats. Internet access, electronic access, and linkages between local, state, and federal data systems are important to these activities.7 Further, local health departments must have access to necessary information to implement and evaluate public health services. All entities involved in preserving the public’s health must be capable of transmitting and receiving critical public health information.19

 

Access to the Internet and Other Electronic Information Systems

 

Overall, information technology makes possible the dissemination and sharing of health care information, regardless of location. It contributes to the trend of boundary-less delivery of health information and health care.35 Improved access to information, particularly through Internet access, further increases the capacity of local health departments to conduct health planning and program evaluation.

 

The lack of equipment availability and electronic access is significant since electronic information systems are efficient methods for obtaining, organizing, analyzing, and disseminating information among communities, states, and agencies at the national level.36 The Internet can link local health departments to their local community, their state, and to national organizations and databases. The Internet can also be used for continuing education and training of public health professionals. Software and communication systems can be used in planning and program evaluation.36

 

Several studies highlight the need for equipment and electronic access. A needs assessment conducted among public health workers in Tennessee found that only 43 percent of respondents in rural counties had e-mail access at work compared with 64 percent of those serving in urban areas. Further, 78 percent of rural public health officials reported that they never or seldom used or needed the Centers for Disease Control (CDC) website versus 70 percent of the urban public health workforce. The only professions reporting 100 percent access to computers at work were environmental engineers, epidemiologists, and physicians—all professions in short supply in rural areas. In addition, only 66 percent of public health nurses reported having access to computers at work.10 These results are similar to those reported in other state surveys.4

 

Less than 50 percent of all public health agencies are estimated to have adequate communications and infrastructure systems. 8  A 1999 CDC and NACCHO e-mail effectiveness test to evaluate access to public health information and to support notification in the event of a health alert or bioterrorism emergency, found only 35 percent of local health departments successfully received a test e-mail message.7 A study of 1,200 local health agencies found that a majority of departments, 83 percent, have personnel with access to public health information through the Internet.3 However, access varied with the population size served by the health agency. While web capacity was 100 percent for health agencies serving populations greater than 500,000, it was only 65 percent for health agencies serving populations less than 25,000.3 In 2001, a CDC study found that overall, only 68 percent of county health agencies had Internet connectivity.9

 

Problems of access to equipment and electronic systems delay communication between public health professionals and health departments at every level. This can lead to problems in other areas of public health infrastructure, particularly surveillance and assessment.

 

Access to Information and Surveillance Data

 

Information and surveillance data improve the ability of public health agencies to recognize, prevent, and intervene in events or risk behaviors that threaten the public’s health. Healthy People 2010 noted that the “capacity of the public health system to measure the health of all individuals requires special attention to groups that may not be identifiable in statewide or national databases.”6 This observation is relevant to the collection of data on rural populations as well. A study of the utilization of Health Information Tennessee, a website that includes health status reports from every county and regional health council in Tennessee, found that 14 percent of urban and 13 percent of rural users accessed the website at least monthly. However, these rates were much lower than the proportion of urban and rural health professionals who reported needing or using county level data at least monthly (50 percent and 47 percent, respectively). At the time of the review, the authors suggested there was a possibility that health professionals may not be aware of the information source or may find barriers in attempting to use it.10 This may signify either a need for training or for increased awareness through information dissemination activities about the recently available resource.

 

Discussions with the Washington State local public health workforce in 1997–1998 found seven key information needs for both rural and urban public health personnel:

 

·       tools and resources that facilitate contact with experts,

·       legislative updates,

·       data set content information,

·       resources for outcome measures and benchmarks,

·       scheduling software,

·       templates for common applications, and

·       databases that offer knowledge-based information.37

 

Such information needs highlight the impact that differences in health professional training and experience have on information and data system utilization and improvement.35

 

Workforce

 

Description of the Public Health Workforce

 

Strengthening the public health workforce is a critical part of infrastructure development. In 2000, the ratio of public health workers overall was approximately 158 public health workers per 100,000 population.38 Metropolitan LPHAs report an average of 108 full-time employees (FTEs) compared with 31 FTEs in non-metropolitan LPHAs.1 Because there are fewer people to provide services in rural areas, and local health departments may be the only source of public health in those communities, rural public health employees must fill many diverse roles.4

 

Additionally, the public health workforce is not limited to health department personnel but rather is composed of many professions. In metropolitan areas, the public health workforce may expand to include anthropologists, epidemiologists, sociologists, economists, public health informaticians, and lawyers; however, a CDC-produced document reports there are no exact data on this extended workforce.7 In rural areas, public health encompasses more diverse professions not usually considered part of the traditional workforce, including: Head Start personnel, school nurses, zoning and planning personnel, community health center staff, community hospital workers, veterinarians, dentists, social workers, tribal council members, long-term care workers, home health personnel, Agency on Aging staff, community action group members, Cooperative Extension personnel, and church members and employees.4

 

The Public Health Workforce Enumeration 2000 compiles workforce statistics on the 50 United States, six territories, and the District of Columbia. Its objective is to build upon a comprehensive national profile of the public health workforce, but there are discrepancies in the workforce classifications used in different state offices. In an attempt to address this, researchers developed a classification scheme or taxonomy for categorizing existing public health workforce information. Another limitation is that the study does not include rural areas but rather portrays a more general picture of the status of the public health workforce at the national, state, and local levels. However, two key points relevant to the rural public health workforce are: 1) in many rural areas, public health nurses provide the majority of care; and 2) the public health workforce is aging and retiring, especially within public health nursing.5

 

Description of the Rural Public Health Workforce

 

The size, scope, and composition of the public health workforce vary widely across the nation, but several studies have attempted to characterize the rural public health system. A study of two rural states, Idaho and Wyoming, conducted in 1998–1999 examined the size and structure of the public health workforce, the formal public health training of the workforce, and the recruitment and retention of public health professionals.39 The report found:

 

·       More than half of the professionals in both states are nurses.

·       In Idaho, environmental health professionals work within district health offices. In Wyoming, environmental health is separate from the local health department and is part of the Department of Agriculture.

·       Idaho’s health departments have a diverse staff, while Wyoming’s health departments are made up of two public health nurses and an administrator.

·       Idaho reports 39 public health professionals per 100,000 people.

·       Wyoming averages 31 public health professionals per 100,000 population.

·       Many have not had formal training in public health.  

 

This study does not provide information on the per capita ratio of local health department professionals. This is important for comparison with other ratios in other states, yet such national data are rare.

 

A survey of Alaska, Montana, and Wyoming found similar data regarding the size of the local health department staffing levels. This three-state survey included 93 rural and 10 urban local health departments.32 The findings were:

 

·       Rural local health departments have fewer than five professionals.

·       The per capita public health workforce supply is greater in rural than in urban local health departments.

·       Public health nurses form the core of rural local health departments, while urban local health departments have a more diverse professional staff.

·       Except Alaska, the majority of the personnel in rural areas work part time.

·       Many of the personnel do not have previous formal public health training.

 

Other predominately rural states have approximately one local health department professional for every 3,225 residents.32 Alaska has more than twice the per capita supply of support staff working within the local health district framework. Montana has only one support staff for every 10,000 people served. Alaska, Wyoming, and Montana report greater proportions of nurses and nurse practitioners in the rural local health departments. Professionals, like health educators or epidemiologists, are not present in the smaller local health departments. There are more differences between rural and urban than between states.32

 

In general, western states that are classified as rural employ one FTE public health nurse for every 6,000 people. Many of these nurses have received no formal training or experience in rural public health. Although nurses in this region may only work part-time, they tend to stay in the position a longer time.34

 

Shortages, Recruitment, and Retention

 

The challenge of strengthening the workforce is greater in rural areas than urban centers because of a variety of issues including location, educational opportunities, and financial constraints that impact upon recruitment and retention of personnel. This is particularly true for public health nurses, but it is also true for other professionals who play an essential role in providing public health services.

 

Efforts to enumerate the public health workforce have been ongoing since 1908. Tallies between 1980 and 2000 indicate a 10 percent decrease in the workforce, illustrating a significant barrier to strengthening the infrastructure and, therefore, limiting planning and development capacities.38

 

Retaining and recruiting qualified public health professionals to serve in rural areas present additional barriers to strengthening the rural public health workforce. Currently, employees retiring from public health exceed the numbers entering the field. Staff tend to migrate from smaller to larger health departments, further exacerbating the shortage of available personnel in rural areas. Recruitment issues include location, limited resources, and lack of access to Master of Public Health (MPH) graduates. In addition, there are limited opportunities to expose public health students to specific rural health practice.4

 

Competencies for Public Health Workers

 

The core competencies represent a nationally defined set of standards for public health professionals, which aim to improve the knowledge and skills of public health workers.11<