Rural
Healthy People 2010:
A Companion Document to Healthy
People 2010
VOLUME 1:
Introduction, Overviews, and Models for Practice
INTRODUCTION
TO RURAL HEALTHY PEOPLE 2010
This document and the Rural
Healthy People 2010 project (RHP2010) described here are intended to maximize
the impact of Healthy People 2010 (HP2010) on health conditions in rural
The impetus for this project
was the recognition that rural areas frequently pose different and, in some instances,
greater challenges than urban areas in addressing a number of HP2010
objectives. There are rural-urban disparities in health conditions associated
with particular preventable or chronic diseases and disparities in
infrastructure or professional capacity to address health needs. There is ample
evidence that some important rural-urban health disparities exist with respect
to, for example, shortages of some types of primary care physicians
(obstetricians and pediatricians), shortages of specialized mental health
providers and oral health providers, prevalence of tobacco use and
drinking-and-driving, and delays in screening and diagnosis of cancer. These
and many other disparities are referenced later in this introduction and
detailed in the following chapters. In addition, particular geographic,
demographic, and cultural conditions in rural areas present obstacles to both
rural residents seeking services and providers who would deliver them. We
should note that although HP2010 publications include some rural-urban
comparison data, a urban-rural chartbook1 provides visual evidence of a number of such
disparities across regions of the country. Also, HP2010 documents include
indicators for benchmarks and targets for many of the HP2010 objectives. These
are not repeated here, but interested readers are encouraged to examine HP2010
documents at their website (http://www.healthypeople.gov).
It is not the purpose of the
Rural Healthy People 2010 project to attempt to address all 28 of the Healthy
People 2010 focus areas or even 100 of 467 objectives examined by so many
experts within the HP2010 process. The purpose of this project and this
document is to provide reviews of the literature highlighting rural disparities
and needs in rural health priority areas and to offer examples of models for
practice addressing selected rural health priority areas.
METHODOLOGY
The starting point for the
Rural Healthy People project was to identify those HP2010 focus areas that
should be considered rural health priorities. A first step in
designing the project involved round-table discussions among many members of
the
Table 1. Initial Criteria for Selecting Rural Health
Priorities.
· Identified by rural people as a high priority.3
· Overall prevalence in rural areas 1, 4
· A disproportionate prevalence in rural areas1, 4
· Impact of the issue on mortality5
· Impact of the issue on morbidity6
· The issue is a contributor to other health
problems7
· The condition’s causes are known8
· Feasible
solutions for rural communities9
· Community interventions are “known” to work
A second step was to begin an
initial literature review and to identify sources of information that might be
used to identify rural health conditions that rated highly on each particular criteria. The nine criteria were then arrayed against the 28
HP2010 focus areas, and each focus area was examined against indicators
identified for each of the nine criteria. A generalized depiction of the
initial sources examined for selection of rural health priorities appears in
Figure 1.
Figure 1. Initial Factors Examined
for Selection of Rural Priorities.
Rural
Health Priority Survey #1 (E-Mail Survey of National and State Experts)
There was scant information on
one criteria¾priorities identified by rural people. To address this
lack, RHP2010 staff conducted an e-mail survey in spring 2001 targeting 90
national and state rural health experts. Included in this survey were all of
the state offices of rural health and selected staff members of ORHP,
Congressional rural caucus, and national rural health research centers.
Respondents were referred to the HP2010 website and then were asked to list
several rural health needs or issues (or goals or
objectives from Healthy People 2010) that came immediately to mind as major
rural health priorities. Forty-four of 90 state and national experts responded.
Table 2 presents the topics that were most frequently nominated as priorities.
Results of this RHP2010 survey (the
first of two) show that nearly all of the respondents’ statements of priorities
fit within the existing 28 focus areas established within the HP2010 document. Of the 14 rural health topics identified by over 20
percent of the respondents, five topics deal with aspects of access — access to
emergency medical services, health services, health workforce, primary care,
and health insurance. Nearly three quarters (73 percent) of the respondents
note one or more access-related topics. The next highest percentages of
nominations for individual topics appearing in Table 2 are for mental health
and oral health. These two areas, too, include other elements of access¾access to mental health professionals and dentists.
Educational and community programs, diabetes, injury and violence prevention,
nutrition and overweight, public health infrastructure, substance abuse, and
tobacco were the remaining seven areas nominated by over 20 percent of the respondents.
|
Table 2. Rural Health Priorities Identified by
National and State Rural Health Experts Spring 2001. |
||
|
Rural Priorities (identified by 15% or more) |
Percent of Respondents (N=44) |
|
|
Access to health care (includes one or more of the
following): |
|
73% |
|
Access to
emergency medical services |
32% |
|
|
Access to
health workforce |
29% |
|
|
Access to
health services (general) |
29% |
|
|
Access to
health insurance |
26% |
|
|
Access to
primary care |
24% |
|
|
Mental
health |
|
49% |
|
Oral health |
|
41% |
|
Educational
and community-based programs |
|
29% |
|
Diabetes |
|
26% |
|
Injury and
violence prevention |
|
26% |
|
Nutrition
and overweight |
|
21% |
|
Public
health infrastructure |
|
21% |
|
Tobacco |
|
21% |
|
Maternal,
infant, and child health |
|
18% |
|
Occupational
safety and health |
|
18% |
|
Cancer |
|
15% |
|
Environmental health |
|
15% |
|
Heart disease and stroke |
|
15% |
Adapted from Gamm and
In this same survey, the national and state rural
health experts were asked to rate, on a five-point scale, the degree of
importance of each of the nine criteria proposed for selecting rural health
priorities for further study. The nine
criteria for assessing rural health priorities, grouped according to three
general levels of importance reflecting the responses, are presented in Table
3.
|
Table 3. Importance Ratings for Criteria for
Selecting Rural Priorities (Average of Ratings) Most Important – (4.3)
·
Has been identified by people
living in rural areas as a high priority health issue for them Very
Important - (4.0)
·
Overall prevalence in rural
areas (i.e., how common is the problem or condition) ·
Whether there is a disproportionate
prevalence in rural areas compared to non-rural areas Important-to-Very Important— (3.7-3.8)
·
Impact of the condition or problem on mortality
·
Impact of the condition or problem on morbidity ·
Is considered to be a contributor
to many other health problems ·
Causes of the condition or
problem are known so that effective
interventions or solutions could be identified ·
Solutions or interventions
are feasibile in rural communities (e.g., not too costly,
not too complicated, does not require major system change at state or
national level) ·
Community interventions or model programs exist
and are “known” to work Note:
Respondents rated the criteria on a five-point scale: 5=Most important,
4=Very Important,
3=Important, 2=Less Important, 1=Not Important. Most respondents chose to
score more than one criteria at a rating of “5”; few rated any of the
criteria at less than “3.” The survey found substantial agreement among the
respondents on the importance of all the criteria, with a heavier emphasis on
a few of these. |
The importance of attending to what “people living in
rural areas” identified as rural health priorities was underscored in
presentation and discussion of the results of the survey at the National Rural
Health Association’s (NRHA’s) annual conference in
Dallas, May 2001.10 Responses to the survey and feedback from staff of
other rural health research centers, ORHP staff members, and other attendees at
the conference suggested a need for a second, broader survey seeking more input
from state and local representatives.
A second survey, using standard mail survey
methodologies12 was conducted from July through October 2001.
Questionnaires were mailed to 975 people representing state and local
organizations with a commitment to rural health. The sample included four
categories: statewide entities (offices of rural health, state primary care
offices, state primary care associations, state rural health associations);
local rural public health agencies; rural health clinics and community health
centers; and rural hospitals, principally critical access hospitals. For
the three categories of local respondents, the project attempted to reach equal
numbers of randomly selected organizations from each state. The local
respondents were selected from lists of the organizations provided by the relevant
federal agencies and trade associations. An additional 24 state and
local rural experts, nominated by respondents, were surveyed as well. After a
reminder and follow-up mailing, 501 leaders of state and local rural
health-focused organizations responded, a response rate of 51.4 percent. Rates
of response varied from 50 percent for rural hospitals to 61 percent for state
agencies and associations.
The respondents, presented
with a list of the 28 HP2010 focus areas, were asked to check five of the 28
that they believed to be top rural health priorities. The survey results
reflected a wide distribution of priority selections, with “access to quality
health services” the one nominated most frequently.13 The priorities
nominated in the second survey were quite consistent with the results of the
first survey; a major exception is the higher rating given to the heart and
stroke focus area in the second survey. The 10 focus areas that were selected
by at least 20 percent of respondents in the second survey were then chosen by
project staff as the nominated rural health priorities to be considered
for inclusion in the Rural Healthy People 2010 companion document (see Table
4).
Shown in Table 4 are the 16
focus areas that were nominated as one of the rural health priorities by 13
percent or more of the respondents, based on average across the four types of
state and local rural leader respondents.14 Two additional focus
areas were nominated by approximately 10 percent of the respondents¾physical fitness and activity, and respiratory
diseases. All of the remaining 10 HP2010 focus areas were nominated as rural
health priorities by an average of 5 percent or less of respondents across the
four state and local groups; these focus areas include arthritis, osteoporosis,
and chronic back conditions; health communication; occupational safety and
health; sexually transmitted diseases; chronic kidney disease; HIV; vision and
hearing; disability and secondary conditions; food safety; and medical product
safety.13
Table 4. Rural
Health Priorities—Organizational and Regional Comparisons by Percentages and
Ranks.
(a) Bold percentages identify priority areas that were
significantly more likely to be chosen by some groups than by others.
†
The top-ranked 16 Healthy People 2010 focus areas according to the average
percentages (left side column) of each of four types of state and local rural
health organizations selecting the focus areas as one of their top five rural
health priorities.
*** Chi Square statistically
significant at p<.001; or ** at p<.01; or * at p<.05.
There are some interesting
variations in priority selections according to the type of state and local
respondent groups and the geographic location of the respondents (classified
according to four major census regions in the United States).14 Such variations are indicated in Table 4 by placing
percentages in bold type and are described in the focus area overviews in
Volume 1 and literature reviews in Volume 2.14
More important may be that
there is substantial agreement on the top five rural health priorities across
the groups of state and local respondents and the regions. Access, for example,
is the top priority among all groups and all regions. The remaining four of the
top five ranking priorities, moreover, received percentage ratings placing them
in the top five for at least three of the state and local respondent groups and
three of the four geographic regions. Additional comments on these priorities are
offered after a preview of the literature review component of this work.
Literature Reviews on Selected Rural Health
Priorities
Rural Healthy People 2010 literature reviews began in the Spring of 2001. Initial discussion projected that access to primary care, diabetes, ment