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 Key Ingredient of the National Prevention Agenda: Workforce Development, is a Health Resources and Services Administration (HRSA)-funded, Public Health Foundation-produced identification resource to help public and private agencies reach workforce development objectives in Healthy People 2010. Two main points emphasized in the document are competency-based continuing education and minority representation in health professions. There are approximately 13 competencies, including cultural competencies and community dimensions of practice skills.40

 

The Office of Workforce Policy and Planning (OWPP), Centers for Disease Control and Prevention, created and revised a collection of competency sets classified by occupation and profession. A limitation of these competency sets is that they are not specifically tailored to the needs of rural public health workers.41 The competency sets are differentiated into the following categories:

 

·       core – basic public health competencies that address the essential services of public health;

·       new topical areas – emerging areas such as emergency response, genomics, and law;

·       functional areas – leadership, management, supervisory, and secretarial;

·       discipline specific – professional, technical entry level, and student; and

·       other topical areas – community-based health, maternal and child health, cultural diversity, STD/HIV, etc.41

 

The HRSA-sponsored Council on Linkages between Academia and Public Health Practice was formed to implement public health competencies. Comprised of leaders of national organizations in public health practice and academic institutions, the Council’s list of core competencies for public health professionals is divided into the following eight domains:

·       analytic assessment skills,

·       basic public health sciences skills,

·       cultural competency skills,

·       communication skills,

·       community dimensions of practice skills,

·       financial planning and management skills,

·       leadership and systems thinking skills, and

·       policy development/program planning skills.12

 

Ultimately, this structure may prove beneficial to public health education and public health practice, and consequently, facilitate delivery of essential public health services in rural areas.13

 

Training in Essential Public Health Services

 

Although there is documented diversity in the education and training of the disciplines that comprise the public health workforce, there is also a general consensus that rural public health workers lack formal training in the concepts and principles of public health. The Public’s Health Infrastructure report indicates 78 percent of local health department personnel did not graduate with public health degrees.7 Conclusions from a recent rural health conference found limited public health training for nurses and members of the local boards of health. Most rural public health nurses were trained in a two-year associate degree program that did not offer public health content within the curriculum. Members of local boards of health, who are the policy-making component of rural public health, are unlikely to have formal training in public health concepts. This deficiency impacts upon the relationship that connects rural health departments with their communities.4

 

In August 2002, a statewide survey provided useful information on the educational background of the Texas public health workforce. For example, 66 percent of the respondents had a college degree or a post-secondary degree, and 26 percent had either a master’s degree or a doctorate degree. However, these advanced degrees did not indicate studies in public health.14

 

The Connecticut Department of Public Health, through its Office of Public Health Workforce Development, conducted a workforce study of training needs. The following results were reported in the “Gap Analysis of Competency Levels” section:

 

·       The training needs vary depending on the unit and job category.

·       There is a lack of formal degree training in the public health workforce.

·       Workshops and individual courses are not sufficient to enhance the perception of skill importance.

·       Most employees had 13 years of public health experience, with an average of 11 years in the department of public health and over seven years of experience in the actual position.

 

In summary, this report indicated a difference between the current competency levels among Department of Public Health employees and those competencies perceived as needed to adequately perform the essential services.42

 

A recent Institute of Medicine report gives insights into how public health educational institutions plan to strengthen public health education, research, and practice. This report cites a correlation between providing the essential services and schools of public health, other programs, higher education schools, and institutions whose main mission is to educate public health professionals. It is necessary for all public health agencies and organizations, including non-profit and for-profit at federal, state, and local levels, to have an interest in educating and training the future public health workforce.41

 

Continuing Education and Training by Public Health Agencies

 

In addition to recruitment and training of the future public health workforce, it is imperative that the continuing education needs of the current workforce are addressed. A 1999–2000 NACCHO survey of LPHA directors across the country responded to local workforce training needs. Eighty percent of agencies serving metropolitan areas and 70 percent of non-metropolitan agencies indicated that they had a budget line item for staff training. Overall, 61 percent of the responding LPHAs indicated job-specific training, such as continuing education programs for nursing and medical credentialing, was a priority. Another 10 percent indicated that information technology training, such as computer or software program training, was a top priority. There was little difference in stated training needs between metropolitan and non-metropolitan agencies.1

 

Researchers in Tennessee asked rural and urban public health workers to self-rate their level of computer expertise.10 Forty-one percent of rural public health workers self-reported a beginner level of expertise, versus 27 percent of urban public health workers; 55 percent of rural public health workers self-reported an intermediate level of expertise versus 57 percent urban public health workers; and 3 percent of rural public health workers self-reported an advanced level of expertise versus 15 percent urban public health workers. These disparities further illustrate the need for information technology training for rural public health workers.

 

The training needs assessment of the Texas public health workforce reported by Borders and Blakely (2002) found that as a group, sanitarians indicated the single greatest need for training, with particular need for training in the essential public health service of enforcing laws and regulations that protect health and ensure safety. Nurses and health educators indicated the greatest need for training across a variety of essential health services including informing, educating, and empowering people about health care issues, mobilizing community partnerships, and developing policies and plans that support health efforts. This assessment also identified several different categories of public health workers who consistently rated enforcing laws and regulations and empowering people about health issues as the priority training needs. In addition, Texas regional offices and local health departments reported a greater need for training in the essential public health services than central office personnel.14

 

Public Health Organizations

 

The public health infrastructure has been defined as a complex web of practices and organizations.7 Public health encompasses three core functions—assessment, policy development, and assurance—which have been expanded into the 10 essential public health services. The totality of the public health infrastructure includes all governmental and nongovernmental entities that provide any of these services.6 At the local level, public health workers are found not only in local health agencies, but also in private and non-profit organizations concerned with the public’s health.

 

The figure below shows the professional public health workforce incorporated within this broader setting.43

 

Figure reprinted with permission from the Journal of Public Health Management and Practice.44

 

National Performance Standards

 

Performance standards have been formulated for use at the local level. These performance standards are based upon the core functions and the 10 essential services; they are designed to measure capacities and systems of public health.15

 

Health Improvement Plans

 

Health improvement plans act as blueprints for improving a community’s health, including developing strategic action steps that direct the distribution of health services and resources more effectively.1 One of the objectives of Healthy People 2010 is to “increase the proportion of local jurisdictions that have a health improvement plan linked with their state plan.”6 More than half of the nation’s LPHAs have developed or participated in the development of a community health improvement plan. However, there are considerable differences in participation rates between metropolitan and non-metropolitan jurisdictions—only 41 percent of LPHAs serving a population of less than 25,000 reported participating in health improvement planning versus 76 percent of LPHAs serving a population greater than 25,000.1

 

Access to Public Health Laboratory Services

 

Public health laboratories, in conjunction with clinical, environmental, and agricultural laboratories, constitute a national laboratory network that fulfills a critical role in assessing and assuring the health of populations and the environment.6 One of the concerns in the public health organization of rural areas is the capacity to access laboratory facilities.16 Although rural hospitals and/or clinics may be prepared for basic laboratory services, they may lack a fully operational surveillance system for disease outbreak.

 

Access to Epidemiology Services

 

All communities must have a health surveillance system that can quickly detect, investigate, and respond to diseases to prevent the unnecessary spread of infection.6 Typically, LPHAs are tasked with providing epidemiology and surveillance services for a community, but the capacity to achieve this goal is correlated to the LPHA type and the size of the service population. Only 56 percent of LPHAs serving single townships, as compared with 92 percent of LPHAs serving multiple counties, provide epidemiology and surveillance services. Only 74 percent of LPHAs serving a population of less than 25,000, versus 98 percent of LPHAs serving a population of 500,000 or more, provide these services.1 In rural areas, responsibility for these services falls on the local hospital’s surveillance capabilities, where they exist. The issue of surveillance capacity is also particularly challenging for rural areas. Because the numbers of affected individuals in rural areas will likely be small, it will be difficult for the systems to identify an unexpected increase in cases prior to a larger outbreak.4

 

Model Statutes Related to Essential Public Health Services

 

A review of state public health statutes shows little correlation between current statutes and the essential public health services framework.17 A recommendation was made to develop a model for each jurisdiction to tailor statutes to local conditions and priorities. To this end, Turning Point created a “model state public health act” to be used as a template for both state and local jurisdictions to bridge the gap between the law and the need to protect the public’s health.18

 

Resources

 

Data on Public Health Expenditures

 

Financial resources drive the public health infrastructure. To allocate resources appropriately and to ensure efficient performance, fiscal expenditures must be documented and explained.6 Documentation of allocations and expenditures of funding for rural public health services should take into account the following conditions:

 

·       Local public health agencies must manage a large number of funding streams.

·       Funding in rural communities may rely more heavily on state tax revenues than in urban areas; when these dollars are tied to specific issues or programs, spending is less responsive to local priorities.

·       Funding in rural communities is also more dependent on service reimbursement than in urban areas.

·       Expansion of Medicaid managed care in rural areas has threatened the ability to provide services to low income residents.4

 

A public health infrastructure that is stretched to its limits and is not up to date with technology, workforce, organizational capacity, and funding needs can have a negative impact on the provision of public health services and a community’s health. The lack of information and data resources and funding for the surveillance, monitoring, and evaluation of a community’s performance may be associated with lower socioeconomic status or size of community.19

 

BARRIERS

 

Funding

 

Funding for local public health departments affects the public health infrastructure significantly. A survey of 1,100 local public health agency directors conducted in 1999–2000 found that yearly expenditures among local public health agencies varied widely and ranged from $0 to $836 million. Gross comparisons show the mean annual expenditures for non-metropolitan agencies were $1.2 million compared to $8.9 million for metropolitan agencies. The smallest jurisdictions averaged $438,000 compared to the largest jurisdictions with $66 million, on average.1

 

Local funding was the main source (44 percent) of funding for local public health agencies followed by state allocations (30 percent); direct federal funding constituted a very small portion (3 percent) of the agency budget. The proportion of local funding varied between metropolitan and non-metropolitan areas (metropolitan areas received more local funding), as well as by the size of the population served.1 More non-metropolitan (41 percent) than metropolitan (26 percent) local public health agencies noted funding was their main challenge.1

 

A survey of local health departments in six communities in states with significant rural populations—Alaska, Idaho, Montana, and Wyoming—found the communities varied in their levels of funding, staffing, services provided, and state involvement. When asked to identify needs, the main needs cited were related to funding.34

 

A Texas report showed the impact funding can have on communication and the ability of local health departments to provide core services.45 Areas with higher income and lower unemployment—usually urban areas—were more likely to have health departments that provided more public health services when compared to areas with lower income and greater unemployment—often rural areas. This may be attributed to the amount of local funding, including tax revenues, the areas receive. To compare differences in state funding practices, the Texas report compiled data from 10 other states. This study confirms that the proportions of local, state, and federal funding vary significantly.45

 

Training

 

Despite important advances in understanding the composition and competency needs of the public health workforce, major barriers exist in assuring the ongoing competency of this workforce:

 

·       Information is limited from which to forecast personnel needs or related training requirements.

·       While progress is being made in competency identification, gaps still exist in availability and accessibility of job-related training and continuing education.

·       An integrated delivery system for life-long learning does not exist.

·       Incentives are inadequate for participation in training and continuing education.

·       A uniform approach and commitment to evaluation are absent.

·       Cohesive funding policies and strategies for funding training and continuing education are absent.46

 

Other challenges to providing training in the essential public health services in rural areas should also be considered. These include diversity in economic factors, demographic make-up, population density, terrain, distance from urban areas, community resources, and public health presence.4

 

PROPOSED SOLUTIONS OR INTERVENTIONS THAT ARE FEASIBLE IN RURAL COMMUNITIES

 

While there is much that remains to be done, several states with significant rural populations have made efforts to strengthen their public health infrastructure. Through the Internet, Missouri has made community profiles available on 25 subjects, including chronic disease at the district, county, and state levels.20 Nebraska made a significant improvement in its public health delivery system by creating additional local health departments. Previously, 22 of 93 counties were served by local public health departments. To address the situation, 14 new departments were created, and two others were modified. As a result, all Nebraska residents can be served through a local health department.20 North Dakota has developed a state strategic plan for health that includes objectives in 10 health topic areas. It is also working with the University of North Dakota to develop a legislative strategy for health. Washington State has published a state public health improvement plan that includes standards, strategies, and recommendations in seven topic areas.20 Some states accredit their local health departments. Wisconsin provides an incentive of additional funding if health departments meet higher standards. This funding incentive has resulted in 85 percent of local health departments in Wisconsin achieving high levels of certification.20

 

Technology

 

Investment in technology and information and data systems is critical since it may be able to buffer the impact of understaffing and under funding, in certain situations. Several information and data-gathering systems exist, and many have made significant improvements. In 1992, the Information Network for Public Health Officials was developed to link public health officials throughout the nation.21 In 1993, the Federation of American Scientists developed ProMED, an e-mail and Internet site that identifies and responds to outbreaks of emerging diseases. It includes over 10,000 individuals in 125 countries. In 1995, the University of Kansas’ Work Group on Health Promotion and Community Development and the AHEC/Community Partners in Amherst, Massachusetts, created the Community Tool Box website. This provides online resources about assessment, strategic planning, leadership and management, designing and adapting interventions, and evaluation and sustainability topics for the promotion and development of community health.22, 23 In 1998, EpiX was created to facilitate information sharing among epidemiologists through the Internet.9 In 1999, the Centers for Disease Control and Prevention began the Health Alert Network to link local public health agencies at the state and local levels and other health organizations as part of an early warning system for emergencies, to provide training opportunities, and to improve Internet access.7, 9 In 2000, the CDC initiated the National Electronic Disease Surveillance System (NEDSS) to assist in the detection of outbreaks.7

 

Efforts at the community level are also needed but are hampered by the lack of community-level data and information necessary for community-customized needs assessments.19 The Rural Health Outreach Initiative was developed to improve health outcomes in rural areas through collaboration and partnerships, in an effort to connect community-oriented primary care projects with local health needs and to supply funding through a mini-grants program for rural communities.24 Evaluation of the Rural Health Outreach Initiative suggests that short-term projects, with moderate amounts of funding, are effective in addressing local needs in rural communities.24 The Turning Point Initiative has created networks of 23 public health partnerships in the country to strengthen the linkages of local public health systems to other sectors at various levels. They focus on policies, evaluation, information technology, social marketing, and leadership.25

 

Assessment and planning is important not only for traditional health agencies, but also other institutions related to the community. The “Planning Handbook for Rural Texas Communities” is an example of customizing strategic planning and training for the community level.47

 

Training and Education

 

The CDC supports several national, state, and international efforts to develop public health leaders through the Leadership and Management Development programs. These programs provide incentives for rural public health professionals to participate in training and continuing education activities through subsidized training and tuition reimbursement.26 Through the development of new learning techniques and technologies, opportunities for leader development will be offered to new and underserved audiences such as new and emerging leaders, workers in rural and remote areas, and those whose work intersects with that of public health.27

 

The 2002 Institute of Medicine report suggests the main research areas should be in population health, primary prevention, public health systems, and community-based participation. In addition, the report provides a framework and recommendations for strengthening public health education, research, and practice skills that can be used by the institutions and organizations responsible for educating public health professionals and supporting public health education. The education and training of public health professionals is important because it will be their responsibility to effectively shape the programs and policies needed to improve population health during the coming century. To employ well-trained and educated public health professionals, there must be the necessary support to see this accomplished.41

 

In an effort to recruit the next generation of public health professionals, Alabama has created the Rural Health Leaders’ Pipeline, a program intended to increase the number of youth interested in pursuing health professions in rural communities in 18 counties.29 Another initiative in Kentucky, attempting to interest young people in public health, incorporated a public health class into the high school curriculum.

 

While the need for continuing education in rural service areas is great, there are challenges that must be addressed to maximize training for this broader audience of public health professionals. Strategies must be instituted to provide training in rural areas rather than requiring long-distance travel. Rural public health workers face major public health challenges in serving low-income and/or racial and ethnic minority populations. This workforce has a greater need for continuing education in cultural competency to address the needs and concerns of racial and ethnic minorities in rural areas.4

 

At the national level, the U.S. Department of Health and Human Services, Health Resources and Services Administration, has recognized the need for continuing education opportunities, currently funding 14 Public Health Training Centers (PHTC) that service 42 states and the District of Columbia. The Centers are partnerships between schools of public health, other academic institutions, and public health agencies to ensure that the public health workforce has access to quality learning programs.28 The PHTC program is designed to improve the nation’s public health system by strengthening the technical, scientific, managerial, and leadership skills and abilities of current and future public health professionals. PHTC resources and networks can be used by any source interested in improving the knowledge base of the public health workforce through training and education.28

 

Various Funding Streams

 

Funding has been allocated to strengthen the public health infrastructure in rural communities. An institution that funds these types of programs is the Robert Wood Johnson Foundation. Two examples—the Turning Point Initiative and Southern Rural Access Program—have had an effect in development of public health and health care infrastructure, capacity building in public health agencies, and supplying providers. In a five-year period, approximately 20 million dollars have been allocated to this cause.48

 

Another type of funding has been the revolving loan fund. This loan fund promotes partnerships to mobilize resources between southern philanthropies and multiple local, state, and federal agencies.

 

A very creative funding scheme is the Rural Local Initiatives Support Corporation (Rural LISC), which provides grants, loans, and equity investments to community development corporations for neighborhood redevelopment.30 The Rural LISC is an integrative approach to strengthening public health funding by building the capacity of resident-led rural community development corporations, increasing their production and impact, demonstrating the value of investing in and through rural community development corporations, and making the resource and policy environment more supportive of rural community development corporations and their work.30 Positive outcomes of the Rural LISC include: 1) the resource mobilization of partner organizations and funding for rural community-based problems; and 2) the formation of alliances between diverse groups or resources with partners, lenders, funders, policy makers, and rural organizations to promote an integrated “rural community development movement.”30

 

COMMUNITY MODELS KNOWN TO WORK

 

Several programs are presented in the Models for Practice section that exemplify community-based approaches to strengthening the rural public health infrastructure.

 

SUMMARY AND CONCLUSIONS

 

According to Syme (2004), addressing funding problems, developing interventions at multiple levels, and working with the wide array of public health workers in rural areas are imperative to improving health at the community level.31 The public health infrastructure is comprised of four components: information and data systems, the workforce, public health organizations, and resources to deliver the essential public health services. The four areas are intertwined and must be addressed in concert. This need is especially pronounced in rural areas, as two-thirds of the local health departments in the U.S. provide services in areas of less than 50,000 people.32

 

REFERENCES

 

1. Hajat, A.; Brown, C.; and Fraser, M. Local public health agency infrastructure: A chartbook. National Association of County and City Health Officials (NACCHO) and the Robert Wood Johnson Foundation. Washington, DC: 1–97, 2001.

 

2. Gamm L; Hutchison, L; Bellamy, G.; et al. Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health 18(1):9–14, 2002.

 

3. Fraser, M. Information technology and local health department. Presentation to the NACCHO Board Annual Meeting, Dearborn, MI. July 1999.

 

4. University of Pittsburgh Center for Rural Health Practice. Bridging the health divide: The rural public health research agenda. Health Resources and Services Administration. Federal Office of Rural Health Policy, 2004.

 

5. Health Resources and Services Administration. The public health work force enumeration 2000. New York: Center for Health Policy, Columbia University School of Nursing, 2000.

 

6. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.

 

7. Centers for Disease Control and Prevention. Public health's infrastructure: Every health department fully prepared; every community better protected, a status report. Prepared for the Appropriations Committee of the United States Senate. Department of Health and Human Services, 2001.

 

8. National Advisory Committee on Rural Health and Human Services, The 2004 report to the Secretary: Rural health and human service issues. 2004.

 

9. Baker, E.J., and Koplan, J. Strengthening the nation's public health infrastructure: Historic challenge, unprecedented opportunity. Health Affairs 21(6):28–30, 2002.

 

10. Lee, P.; Giuse, N.; and Sathe, N. Benchmarking information needs and use in the Tennessee public health community. Journal of the Medical Library Association 91(3):322–336, 2003.

 

11. Public Health Foundation. Public Health Infrastructure. Public Health Foundation, 2003.

 

12. Council on Linkages. About the Council on Linkages between Academia and Public Health. n.d.

 

13. Public Health Foundation. Council on Linkages between Academia and Public Health Practice. 2004.

 

14. Borders, S., and Blakely, C. The ten essential public health functions: Assessing the training needs of the Texas public health workforce. Prepared for the Texas A&M University System Health Science Center, School of Rural Public Health, 1–46, 2002.

 

15. Association of State and Territorial Health Officials. Policy Position Statements, 2002.

 

16. Heinrich, J. Infectious diseases: Gaps remain in surveillance capabilities of state and local agencies. U.S. General Accounting Office. Testimony before the Subcommittee on Emergency Preparedness and Response, Select Committee on Homeland Security, House of Representatives (GAO-03-1176T):1–17, 2003.

 

17. Gebbie, K.M. State public health laws: An expression of constituency expectations. Journal of Public Health Management Practices 6(2):46–54, 2000.

 

18. Turning Point. Collaborating for a new century of public health, model state public health act: A tool for assessing public health laws. Public Health Statute Modernization National Excellence Collaborative, 2003.

 

19. Lurie, N. The public health infrastructure: rebuild or redesign? Health Affairs 21(6):15–27, 2002.

 

20. Congressional Quarterly. Public health: Costs of complacency. Washington, DC. Governing, City and State, 2004. February 24, 2004.

 

21. Baker, E.; Friede, A.; Moulton, A.D.; et al. CDC's information network for public health officials (INPHO): A framework for integrated public health information and practices. Journal of Public Health Management Practice 1(1):43–47, 1995.

 

22. Community Tool Box. Community tool box: Bringing solutions to light. 2004.

 

23. Fawcett, S.B.; Francisco, V.T.; Schultz, J.A.; et al. The community tool box: A web-based resource for building healthier communities. Public Health Reports 115(2-3):274–278, 2000.

 

24. Glasser, M.; Holt, N.; Hall, K.; et al. Meeting the needs of rural populations through interdisciplinary partnerships. Community Health 26(3):230–245, 2003.

 

25. Turning Point. What is Turning Point? 2003.

 

26. Setliff, R.; Porter, J.E.; Malison, M.; et al. Strengthening the public health workforce: Three CDC programs that prepare managers and leaders for the challenges of the 21st century. Journal of Public Health Management Practice 9(2):91–102, 2003.

 

27. Centers for Disease Control and Prevention. Leadership and Management Development Programs. 2003.

 

28. Health Resources and Services Administration. Public Health Training Centers. Bureau of Health Professions, 2004.

 

29. Rackley, B.; Wheat, J.R.; Moore, C.E.; et al. The southern access program and Alabama's rural health leaders' pipeline: A partnership to develop needed minority health care professionals. The Journal of Rural Health 19(5):354–360, 2003.

 

30. Rural Local Initiatives Support Corporation. Rural Local Initiatives Support Corporation. 2001.

 

31. Syme, S. Social determinants of health: The community as an empowered partner. Preventing Chronic Disease Public Health Research, Practice and Policy 1(1):1–5, 2004.

 

32. Rosenblatt, R.; Casey, S.; and Richardson, M. Rural-urban differences in the public health workforce: Findings from local health departments in three rural western states. University of Washington: WWAMI Center for Health Workforce Studies, Working Paper 61:1–27, 2001.

 

33. Hajat, A.; Stewart, K.; and Hayes, K. The local public health workforce in rural communities. Journal of Public Health Management Practice 9(6):481–488, 2003.

 

34. Rosenblatt, R. and Rosenblatt, F. The role and function of small, isolated public health departments: A case study in three western states. University of Washington: WWAMI Center for Health Workforce Studies, Working Paper #65:1–20, 2001.

 

35. Kaplan, B.; Brenna, P.F.; Dowling, A.F.; et al. Toward an informatics research agenda: Key people and organizational issues. Journal of the American Medical Information Association 8(3):235–241, 2001.

 

36. National Association of County and City Health Officials, Resolution concerning local public health agency staff access to the Internet. National Association of County and City Health Officials, 2004.

 

37. Centers for Disease Control and Prevention. Information needs and uses of the public health workforce – Washington, 1997–1998. Morbidity and Mortality Weekly Report 49(6):118–120, 2000.

 

38. Merril, J.; Btousch, R.; Gupta, M.; et al. A history of the public health workforce. Journal of Public Health Management Practice 9(6):459–470, 2003.

 

39. Richardson, M.; Casey, S.; and Rosenblatt, R. Local health districts and the public health workforce: A case study of Wyoming and Idaho. University of Washington: WWAMI Center for Health Workforce Studies, Working Paper #56:1–25, 1999.

 

40. HRSA. The key ingredient of the national prevention agenda: Workforce development: Companion document healthy people 2010. Washington, DC: Health Resources and Services Administration, i–47, 2001.

 

41. Institute of Medicine. Who will keep the public healthy? Educating public health professionals for the 21st century. Committee on Educating Public Health Professionals for the 21st Century, 2002.

 

42. Connecticut Department of Public Health. A study of the training needs in the Connecticut Department of Public Health. Office of Public Health Workforce Development. 2002.

 

43. Kennedy, V.C.; Spears, W.D.; Lov, H.D., Jr.; et al. Public health workforce information: A state-level study. Journal of Public Health Management Practice 5(3):10–19, 1999.

 

44. Novick, L. Public health workforce information: A state-level study: Figure 1. Journal of Public Health Management and Practice 5(3):12, 1999.

 

45. Lyndon B. Johnson School of Public Affairs, University of Texas at Austin; School of Public Health, Health Science Center, University of Texas at Houston; Backland Research Center, Texas Agricultural Experiment Station, The Texas A&M University System; School of Rural Public Health, The Texas A&M University Health Science Center. The state of public health: Local and state government issues in Texas: Report resulting from House Concurrent Resolution 44 of the 75th Legislature, 1–77, 1998.

 

46. Centers for Disease Control and Prevention. Strategic plan for public health workforce development: Toward a life-long learning system for public health practitioners. Agency for Toxic Substances and Disease Registry, 2000.

 

47. Lower Colorado River Authority. Planning handbook for rural Texas communities. Lower Colorado River Authority, Austin, TX. 1–83, 2003.

 

48. Beachler, M.; Holloman, C.; and Herman, J. Southern rural access program: An overview. Journal of Rural Health 19(Supplemental):301–307, 2003.

 

Chapter Suggested Citation

 

Quiram, B.; Meit, M.; Carpender, K.; Pennel, C.; Castillo, G.; and Duchicela, D. Rural Public Health Infrastructure: A Literature Review. In Gamm, L. and Hutchison, L. (eds.) Rural Healthy People 2010: A companion document to Healthy People 2010. Volume 3. www.srph.tamushsc.edu/rhp2010. College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.