Rural Public Health Infrastructure

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.

 

PREVALENCE

 

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. Only 4 percent of all LPHAs serve large metropolitan areas with populations over 500,000.1 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.

 

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

 

A number of studies have identified rural-urban disparities in access to and adequacy of information systems. According to the National Advisory Committee on Rural Health and Human Services, less than 50 percent of all public health agencies are estimated to have adequate communications and infrastructure systems.8 A 1999 Centers for Disease Control (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 while web connectivity 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

 

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. 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).10 This may signify either a need for training or for increased awareness through information dissemination activities about the recently available resource.

 

Workforce

 

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 reducing 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

 

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 The Health Resources and Services Administration (HRSA)-sponsored Council on Linkages between Academia and Public Health Practice lists core competencies for public health professionals, divided into eight domains.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

 

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 Health’s Infrastructure report indicates 78 percent of local health department personnel did not graduate with public health degrees.7 A statewide survey on the educational background of the Texas public health workforce found 66 percent of the respondents had a college degree or a post-secondary degree, and 26 percent had either a master’s or a doctorate degree. However, these advanced degrees did not indicate studies in public health.14

 

Public Health Organizations

 

The public health infrastructure has been defined as a complex web of practices and organizations.7 This web includes all governmental and nongovernmental entities that provide any of these services.6 At the local level, public health workers are found in local health agencies, as well as private and non-profit organizations concerned with the public’s health. Components to consider in the evaluation of the public health organizational structure include performance standards for essential public health services, health improvement plans, access to public health laboratory services, access to epidemiology services, and model statutes related to essential public health services.

 

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 and are designed to measure capacities and systems of public health.15

 

Health improvement plans act as blueprints for improving a community’s health.1 More than half of the nation’s LPHAs have developed or participated in the development of a community health improvement plan, but there are considerable differences 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

 

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.

 

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; however, 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.4

 

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

 

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 lack of 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 for local public health departments significantly affects the public health infrastructure. 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.1 More non-metropolitan (41 percent) than metropolitan (26 percent) local public health agencies noted funding was their main challenge.1

 

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

 

PROPOSED SOLUTIONS

 

While there is much that remains to be done, several states with significant rural populations have made efforts to strengthen their public health infrastructure by making health information available to rural areas, adding local health departments, developing a public health improvement plan, and offering financial incentives if health departments meet higher accreditation standards.20 Other solutions include linking local public health agencies and other health organizations at the state and local levels as part of an early warning system for emergencies, to provide training opportunities, and improve internet access; developing networks through databases, e-mail, and Internet sites to facilitate information sharing and detection and response to outbreaks of emerging diseases; and providing online resources about community assessment, intervention planning, evaluation, and sustainability topics.21-23,9, 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.24 The Turning Point Initiative 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.25 The CDC supports several national, state, and international efforts to develop public health leaders through the Leadership and Management Development programs.26 Through the development of new learning techniques and technologies, opportunities for leader development will be offered to new and underserved audiences.27

 

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 HRSA’s Public Health Training Center program has recognized the need for continuing education opportunities and 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.28

 

In an effort to recruit the next generation of public health professionals, Alabama and Kentucky have created programs and courses to interest youth in pursuing health professions in rural communities.29 Funding has been allocated to strengthen the public health infrastructure in rural communities through such foundations as Robert Wood Johnson Foundation, Rural Local Initiatives Support Corporation, and the revolving loan fund.30

 

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

 

MODELS FOR PRACTICE

 

The following models for practice are examples of programs utilized to address this rural health issue.

 

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 He