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, mental
health, and several other topics would be among the rural health priorities
selected for the companion document.
Literature reviews focused on
numerous sources including, but not limited to, the following:
- PubMed (combines MEDLINE® and HealthSTAR),
- PsycInfo,
- Sociology Abstracts,
- Social Services Abstracts,
- Foundation websites,
- Government agencies’ websites,
- RICHS - USDA,
- CRISP - NIH,
- Non-governmental organizations (NGOs), and
- General Internet sources.
Additionally, several recent
books2, 15, 16 and reports1 and a supplemental issue of the Journal of Rural
Health (2002) on rural health research that address a number of RHP2010
conditions were examined. Loue and Quill16 and the supplemental issue of the Journal of Rural
Health appeared while the project was underway; a pre-publication draft of
the urban-rural chartbook1 was available to the staff at the beginning of the
project.
Selection of specific topics
and subjects within each priority area were guided by specific Healthy People
2010 objectives identified by respondents in the survey and/or expertise of the
researcher. Initial scanning for resources was guided by the nine criteria
initially established for selecting rural health priorities for study; an
initial, though not exclusive, focus on literature appearing from 1990 and
later; and literature focused on American rural health topics (apart from some
on basic medical studies). The research literature considered around each of
the rural health priorities extends through 2001 and part of, if not all, of
2002. In a couple of instances, work from early 2003 was added.
Two of the top 12 ranked
rural health priorities were excluded from consideration in this first round of
work¾Education and Community-Based
Programs, and public health infrastructure. Initial exploration of these two
focus areas revealed a relative paucity of literature providing direct rural
and urban comparison of such programs and infrastructures, and difficulty in
matching treatment of these topics to the criteria used in researching and
reporting the literature reviews. The team recognized, too, that a number of
illustrations related to these two topics would be reflected in the models for
practice targeting the other focus areas addressed in this volume.
At the same time, objectives
within the focus area, access to quality health services, were found to be too
diverse to be treated effectively in a single review. Three separate literature
reviews appear under this heading—access to insurance, access to primary care,
and access to emergency medical services.
Discussion turns now to a
brief introduction of each of the 12 areas, drawing on information related to
the initial criteria employed in assessing rural health priorities.
Rural Healthy People 2010 Areas Addressed
Access
to insurance
to support health care continues to be a problem in rural areas¾a problem associated with a lower paid
workforce reliant upon small employers that are less likely than larger
employers to offer health insurance.17 Although there are some regional variations, the percentages of
persons under 65 who are uninsured are higher in rural areas and large central
metropolitan counties than in fringe counties in large metropolitan areas or in
small metropolitan counties.1 Insurance is a major factor in assuring “access to health care,” one
of the 10 “leading health indicators” selected through a process led by an
interagency workgroup within the U.S. Department of Health and Human Services.9 Access to health insurance is named by over one-quarter of national
and state experts as a rural health priority.10 This topic is included within the HP2010 focus area of Access to
Quality Health Services, which is the HP2010 focus area most frequently
selected as a rural health priority in a survey of state and local rural health
leaders.13
Access
to primary care remains a major concern in many rural areas across the nation. There is
a lower supply of all types of physicians, except family practitioners and
general practitioners, in rural areas in all four regions of the nation.1 Access to timely and effective primary care is deemed critical to
avoiding hospitalizations for ambulatory care sensitive conditions. “Access to
health care” is one of the 10 “leading health indicators” selected through a
process led by an interagency workgroup within the U.S. Department of Health
and Human Services.9 Health manpower shortages and recruitment and retention of primary
care providers are identified as major rural health concerns among state
offices of rural health.3 Nearly 30 percent and nearly one-quarter of national and state rural
health experts name access to health workforce and/or access to primary care,
respectively, as rural health priorities.10 This topic is included within the HP2010 focus area of Access to
Quality Health Services, which is the HP2010 focus area most frequently
selected as a rural health priority in a survey of state and local rural health
leaders.13
Access
to emergency medical services (
Heart and stroke,
especially heart disease, continues to be a very serious illness across the
country. “Diseases of the heart” ranks first among the leading causes of death
in 1999.11 Stroke is the third
ranking leading cause of death in 1999.11 Heart diseases are the
most frequently first-listed diagnoses for hospital discharges nationally.6 “Heart failure and shock”
is the most frequent diagnostic category among hospitalized rural elderly
Medicare beneficiaries.4 This point is all the
more important in light of the fact that congestive heart failure,
hypertension, and angina are “ambulatory-care-sensitive” conditions that can
result in hospitalizations because of the lack of timely and effective primary
care and preventive services.8 Heart disease and stroke
is in a virtual tie with diabetes as the second-most frequently selected rural
health priority in a survey of state and local rural health leaders.13
Diabetes mellitus is the
sixth ranking leading cause of death in 199911 and is characterized frequently
as an “epidemic.” Diabetes is an “ambulatory-care-sensitive” conditions for
which hospitalizations can often be avoided with timely and effective primary
care and preventive services.8 Diabetes was named by
over one-quarter of national and state experts as a rural health priority.10 This illness is in a
virtual tie for second place with the area of heart disease and stroke as the
HP2010 focus area most frequently selected as a rural health priority in a
survey of state and local rural health leaders.13
Mental
health and mental disorders is
another HP2010 focus area widely recognized as a pressing rural health
priority. Mental health is one of the 10 “leading health indicators” selected
through a process led by an interagency workgroup within the U.S. Department of
Health and Human Services.9 The suicide rate among rural males is higher than
among their urban counterparts across all four regions of the nation.1 Psychoses are a diagnostic area virtually tied with
cancer as the fourth most frequently first-listed diagnoses for hospital
discharges nationally.6 Access to mental health services and concerns for
suicide, stress, depression, and anxiety disorders were identified as major
rural health concerns among state offices of rural health.3 Mental health is named by nearly 50 percent of national and state
experts as a rural health priority behind access to health care.10 A survey of state and
local rural health leaders finds mental health and mental disorders to be the
fourth most often identified rural health priority.14
Oral health is increasingly recognized as a serious rural health
problem. Nationally, rural areas record higher rates of people 65 and older
with total tooth loss than do their urban counterparts. Among the four regions,
only in the Midwest is this rural rate exceeded by the small metropolitan
counties.1 Shortages of dentists are
more common in rural areas in all four regions of the country.1 Dental care, as measured
by dental visits within the past year, tends to be lower among 18-64 year-old
people in rural areas than in urban areas across all four regions of the
country.1 Dental
conditions, too, are identified as “ambulatory-care-sensitive
conditions.”8 Dental shortages are
identified as major rural health concerns among state offices of rural health.3 Oral health is named by
over 50 percent of national and state experts as a rural health priority behind
access to health care and mental health.10 Oral health is the fifth
ranking rural health priority in a survey of state and local rural health
leaders.13
Tobacco
use is a
practice that continues to disproportionately plague rural people. It is one of
the 10 “leading health indicators” selected through a process led by an
interagency workgroup within the U.S. Department of Health and Human Services.9 Rural adolescents (except in the Midwest) are more likely than their
urban counterparts to smoke.1 Adult men and women in the most rural counties, with some variation
across regions, are more likely to smoke than those in urban counties.1 Tobacco use holds the dubious distinction of being ranked as the
leading “actual cause of death” in the United States, i.e., contributing to the
diagnosed condition associated with a death.7 Tobacco use is in a virtual tie for sixth place (with three other
topics) among HP2010 focus areas most frequently selected as a rural health
priority in a survey of state and local rural health leaders.13
Substance
abuse,
including alcohol use, is common in many rural areas of the country. Alcohol
has been ranked as the third leading “actual causes of death” in the United
States, i.e., contributing to the diagnosed condition associated with a death.7 Illicit use of drugs has been ranked as the ninth leading “actual
cause of death” in the United States.7 Substance abuse is one of the 10 “leading health indicators” selected
through a process led by an interagency workgroup within the U.S. Department of
Health and Human Services.9 Access to mental health and behavioral health services, including
substance abuse, were identified as major rural health concerns among state
offices of rural health.3 Substance abuse is in a virtual tie for sixth place (with three other
topics) among HP2010 focus areas most frequently selected as a rural health
priority in a survey of state and local rural health leaders.13
Maternal,
infant, and child health are significant challenges in many rural areas. Infant mortality is
higher in rural areas in the South and Western regions.1 Adolescent mortality is higher in rural areas in all four regions of
the country.1 The focus area, maternal, infant, and child health, is in a virtual
tie for sixth place (with three other topics) among HP2010 focus areas most
frequently selected as a rural health priority in a survey of state and local
rural health leaders.13
Nutrition
and overweight
is a HP2010 focus area that is increasingly recognized as a serious problem in
many rural areas across the nation. Rural areas exhibit higher self-reported
rates of adult obesity than urban areas, but there is considerable variation
among men and women in urban and rural areas across regions.1 Diet and activity patterns have been ranked second only to tobacco as
the leading “actual causes of death” in the United States, i.e., contributing
to the diagnosed condition associated with a death.7 Nutritional disorders with complications and comorbidities
are the ninth most frequent diagnostic category among hospitalized rural
elderly Medicare beneficiaries.4 Overweight and obesity are one of the 10 “leading health indicators”
selected through a process led by an interagency workgroup within the U.S.
Department of Health and Human Services.9 Nutrition and overweight is in a virtual tie for 10th place
(with two other topics) among HP2010 focus areas most frequently selected as a
rural health priority in a survey of state and local rural health leaders.13
Cancer is the second leading cause
of death in 1999.11 Cancer and psychoses are virtually tied as the fourth most frequently
first-listed diagnoses for hospital discharges nationally.6 Cancer is in a virtual tie for 10th place (with two other
topics) among HP2010 focus areas most frequently selected as a rural health
priority in a survey of state and local rural health leaders.13
Further
Consideration of Rural Priorities
The emphasis in this work on rural health priority
areas is not meant to imply that other HP2010 focus areas are not important in
rural
Survey
results reported in Table 4 suggest that, for a few of these priorities, one or
two groups of rural health leaders may champion these concerns within rural
communities. For other HP2010 focus areas, however, fairly substantial support
is reflected across all leader groups: e.g., for areas such as substance abuse,
and maternal, infant, and child health.
Fewer
significant differences in rural health priorities were noted across regions
than across types of respondents. Nonetheless, for some HP2010 focus areas,
differences in ratings by types of organization or by region might recommend
latitude within rural health policies that allow rural stakeholders to tailor
rural health initiatives to certain regional needs or organizational
circumstances. Some recognition of unique demands posed in particular regions,
for example, is reflected in federally funded or foundation-funded efforts
targeting Southern states, frontier regions, border regions, the Appalachian
region, and the like.
For
those focus areas where there are differences among the four groups of rural
health leaders, such differences might reveal strengths in addressing top
priorities in a collective fashion. For
example, the priority emphasis placed upon chronic diseases such as heart
disease and diabetes by rural hospitals and rural health clinics/centers is
quite congruent with the emphasis of public health agencies upon tobacco use
and nutrition and overweight. The organizations may be addressing the “same”
problem at different points of intervention. These rural health stakeholder
groups reflect different perspectives, skills, strategies, and points of
contact with rural patients, clients, and populations.
Such differences in rural priorities
across types of rural leaders may argue in favor of cross-cutting health
organizations, coordinating bodies, or associations at state and local levels
that can ensure attention to the multiple health priorities facing rural
communities. Substantial agreement combined with selective differences on rural
health priorities among rural health leaders may be viewed as strengths and
ones that can best be optimized by a variety of health professionals and
organizations coordinating their efforts on many of these priorities. Rural
Healthy People 2010: A Companion Document to Healthy People 2010 presents
dozens of models for practice related to many rural health priorities that
reflect just such coordination.
MODELS FOR PRACTICE IN RURAL HEALTHY PEOPLE 2010
A major goal of the Rural Healthy People 2010 project
is to offer guidance to states, communities, health organizations, and
professionals on how these rural health priorities might be attacked. The
approach taken here was to look at what has worked in other settings, analyze
key components of such efforts, summarize the particular approaches against a
standard set of criteria, and provide a contact person for interested parties
to reach for more information.
The first step was to define the set of initiatives or
programs we wanted to examine and report on. The terms “best practices” and
“model programs” were most often used as a general reference to the types of
programs and practices considered relevant to this study. We researched these
and related concepts to help identify criteria for selecting specific practices
or programs we would identify, analyze, and share with others.
Best practices
traces its lineage back to “benchmarking,” typically wherein some organizations
identify “benchmark” organizations to which they aspire and attempt to discover
and replicate those practices that appear to account for exceptional
performance. Best practices has also come to be
associated with performance of professionals and programs, often in association
with “evidence-based” successful outcomes. Some of the definitions and attributes
we have found to be associated with “best practices” are the following:
a technique or methodology that, through experience and research, has proven to reliably lead to a desired result;
fully implemented programs, benchmarked and tested, that demonstrate significant improvement (in processes or outcomes);
- intervention
strategies that have been successfully:
Ø replicated one or more times and
consistently produced positive results, or
Ø
implemented
in different settings, and/or with different populations, and/or across a
variety of different problems with positive results.
Model programs
is a term that has
been employed widely in governmental and nonprofit organizations (especially in
health and human services) to characterize organized efforts, frequently in the
form of formal programs, that demonstrate success over a period of time. Review
of the use of this term found the following characteristics associated with the
term “model programs”:
- innovative,
- problem-based,
- coordinate
organizations and services,
- combine various
approaches,
- new technologies,
- new application of an
existing technology,
- represent radical
changes to existing practices,
- may or may not be
theory based, and
- experimental and subject to testing.
Criteria: Models
for Practice (MFP)
Conceptual elements from both
model programs (MP) and from best practices (BP) were weighed against the
purpose of the Rural Healthy People 2010 project and the predominantly public
health and community health perspective sought from our team (RHP). From this
deliberation, the following criteria were developed to guide the selection and
analysis of what we call “models for practice”:
- located in or serves
rural area (RHP),
- addresses one or more
of the high-priority rural health focus areas (RHP),
- community-based (RHP),
- local or regional
(RHP),
- clear stakeholders and
partners (RHP),
- formal structure
(RHP),
- continuity (in place
three years or longer) (MP),
- growth (serves more
people, larger region, addresses more conditions) (MP),
- movement from pilot
mode to full implementation (MP),
- evidence of increased
commitment from original stakeholders (MP),
- buy-in by additional
stakeholders (MP),
- financial stability
(MP),
- positive outcomes (MP,
BP),
- replicable across
settings (BP),
- breadth of
applications (BP),
- dissemination of
method/technique (BP), and
- recognition in regulatory and/or funding guidelines (BP).
Ultimately,
these criteria were reflected in a very brief “screening survey” that was used
to interview MFP nominee spokespersons, in a more detailed survey (executed by
phone, e-mail, or mail delivery) for those MFPs that
were screened into a pool of potential candidates, and in the four broad topic
areas around which each of the selected MFPs is
summarized.
Folding
MFP criteria into each MFP summary begins with a “Snapshot” that captures the location
and priority area addressed along with a brief description of its activity.
This is followed by the “Model” section that is organized around four topic
areas. The “Blueprint” describes the focus, location, structure, stakeholders,
and activities characterizing the model. The “Making a Difference” section
addresses in more detail the activities and outcomes flowing from the model.
The “Beginnings” section describes the roots and initiation of the model and
its initial growth. Finally, the “Challenges and Solutions” section examines
such things as barriers and/or opportunities encountered,
strategies for addressing them, and implications for continuity or growth of
the MFP.
The respondents to the Rural
Healthy People 2010 survey nominated over 250 MFPs. In addition, professional associations,
foundations, and other individuals identified several dozen MFPs.
Over a dozen were encountered in literature reviews or in newsletters and trade
journals. Altogether, over 300 MFPs nominations were
considered.
Eventually, we examined the “Models
that Work” from the Bureau of Primary Health Care to identify one or two models
in a couple of rural health priority areas where we had not found enough solid
candidate models. Although some of our MFPs turned
out to have received one of HRSA’s Community Access
Program (CAP) grant awards, we did not go to the list of awardees to draw MFPs. These are good sources, to be sure, but we did not
wish to duplicate models or otherwise over-rely on those that were already
recognized and widely publicized.
For each of the RHP2010 priority areas reviewed in the
companion document, three or four MFPs illustrating
how some rural areas are addressing these challenges are typically presented
for each priority area in the printed copies of RHP2010. Additional Models for
Practice appear in the web version.
Some
programs have been in place for longer periods of time than others and,
therefore, are able to share more information allowing the presentation of a
more detailed description of the program.
It should be noted, too, that the RHP2010 document and website do not include
an exhaustive listing of MFPs. Some additional models
are being considered for inclusion under two other
RHP2010 focus areas that will be added to our website in Fall 2003. Still
others are associated with focus areas to be added after that. Some sites that
are responsible for currently listed MFPs under one
priority area are engaged in other MFP-caliber programs addressing other focus
areas. Finally, we anticipate that the publication of RHP2010 will encourage the
nomination of still other excellent MFPs. The current
group of MFPs, of course, covers a wide range of
topics, approaches, and geographic areas of the country.
The MFPs
can be differentiated along a number of dimensions:
- sponsorship: single
organization vs. multiple organizations;
- sector: government,
nonprofit, or for-profit vs. multi-sector;
- rural to urban: rural
only vs. urban-anchored initiative serving rural region;
- illness targeting:
single illness vs. multiple health conditions;
- age targeted:
children/youth vs. elderly;
- health system
dimensions: formal care providers vs. community health;
- geographic scope:
single community vs. multi-state regional;
- degree of
institutionalization: active for many years vs. a few years; and
- major barriers identified: transportation,
attitudinal-cultural.
One or two of the MFPs considered in this volume are clearly viewed as
temporary or transitory interventions that are intended to meet a need until a
preferred, longer term solution is attained.
OTHER SOURCES OF INNOVATIVE MODELS
A
number of best practices in public health at the state level are published by
the Assistant Secretary for Health in the U.S. Department of Health and Human
Services, addressing one or more of the Healthy People 2010 objectives (http://www.osophs.dhhs.gov/ophs/BestPractice).
Other models related to HP2010 objectives
can be found at the Bureau of Primary Health Care website focused on “Models
that Work.” Recent winners of that designation can be found at their website
(http://bphc.hrsa.gov/mtw/).
Information
on dozens of rural outreach grant recipients of funding from the U.S. Office of
Rural Health Policy from 1994 to the current year may be another source of
information on promising programs (http://ruralhealth.hrsa.gov/funding/outreach.htm).
The Community Access Program
of the Bureau of Primary Health Care provides grant support to networks of
organizations intending to improve services to the uninsured and underinsured.
The past three years’ grantee recipients, a number of them rural focused, are
identified on the CAP website (http://bphc.hrsa.gov/cap).
DATA AND DATA SOURCES FOR RHP2010
Data
and data sources for many HP2010 objectives, and rural-urban comparisons, in
some instances, can be found in HP2010 documents. The documents can be found at
the Healthy People 2010 website (http://www.healthypeople.gov).
CDC Wonder is a web-based information resource that enables the user to
access a wide variety of Healthy People 2010-related data. It has a specific
page that is devoted to a Healthy People 2010 database that can be searched by
HP2010 focus area or objective. It includes a wide range of public health data
and information resources addressing other topics, as well, at national, state,
and, in many instances, county level (CDC Wonder, http://wonder.cdc.gov and http://wonder.cdc.gov/data2010).
The
Urban and Rural Health Chartbook (Eberhardt,
et al., 2001)1 cited frequently in this volume provides urban and
rural comparisons nationally and across the four census regions for information
related to many of the rural health priorities discussed in this document. This
resource can also be found at the
Data
on ambulatory care sensitive conditions may be available from state agencies in
some states that collect hospital discharge (admissions) data, including
diagnosis-related data that may be captured and reported by facility, zip code,
and/or county.
Rural
Populations and Health Care Providers: A Map Book offers maps providing a visual picture of
the geographic distribution of rural populations, the racial characteristics of
rural populations, and the health care providers who serve rural populations.
Among the rural providers mapped are primary care physicians (per 200
population), Critical Access Hospitals, Federally Qualified Health Centers,
Rural Health Clinics, and Skilled Nursing Facilities.18
The
Kaiser Family Foundation provides “state health facts online” at their website
(http://www.statehealthfacts.kff.org).
The
HRSA Community Health Status Indicators website was retired as of October 11,
2002. The website (http://www.hrsa.gov/CHSINotice.htm) recommends that
interested parties contact the following sources:
- State health
departments, which may be a potential source for data by county.
The
U.S. Census Bureau State and County Quick Facts can be found at the following
website: http://quickfacts.census.gov/qfd/states/48000.html. For each state and
its counties, it provides basic data on population (population size, age,
ethnicity, education, home ownership, households and household size), income,
poverty status, business/employer facts, employment, geographic area, and
population density.
The Area Resource File (ARF) is a health resources information system
containing more than 6,000 variables (including information over a number of
years) for each of the nation’s counties. It is designed to be used by
planners, policymakers, researchers, and other professionals. It contains data
on health professions, health facilities, populations, hospital utilization,
and a variety of other subjects (http://www.arfsys.com/main.htm). ARF also
identifies a number of more specific sources from which it gathers data.
Although much of the ARF data are quite current, more recent data or additional
data for some subjects may be available from other sources and/or within
particular states.
In
addition to state health department data, some states may have one or more
“integrative databases” that draw on a number of sources related to many health
and population-related topics. A very good example is the Landscape Project at
the Texas Institute for Health Policy Research (http://66.241.202.7/index.cfm).
It draws upon a number of federal and state government sources for its
database, which enables the user to compare the counties in the state with one
another or with all counties in the state. Among the topics included in
Landscape are:
- communicable diseases,
- crime,
- environmental health,
- government finance,
- the health care sector,
- health insurance,
- household information,
- infant and maternal health,
- mortality statistics,
- needs-based programs,
- population projections,
- population distribution,
- Social Security, and
- socioeconomic characteristics.
These and other
sources of information can be used to establish a baseline for a community
regarding health conditions. Such information, along with patient, client, and
student information from local organizations can be employed (subject to
privacy restrictions) to evaluate progress resulting from interventions. The
following overviews of the literature suggest some of the types of information
that may be important. The overviews and models for practice are intended to be
most useful in identifying problems, possible contributing factors and
consequences, and organizations and communities that have taken important steps
to address such problems.
REFERENCES
1. Eberhardt, M.; Ingram, D.;
Makuc, D.; et al. Urban and Rural Health Chartbook. Health United States, 2001. Hyattsville, MD: National Center
for Health Statistics, 2001.
2. Ricketts, T.C. (ed).
Rural Health in the United States. New York,
NY: Oxford University Press, 1999.
3. National Rural Health Research Center
Director's Meeting. State Office of Rural Health Research
Interests Survey Results. Washington, DC, March 5, 2001.
4. Buczko, W. Rural Medicare beneficiaries’ use of rural and
urban hospitals. Journal of Rural Health
17(1):53-58, 2001.
5.
Centers for Disease Control and Prevention. 10 Leading Causes
of Death, United States, 1999. <http://webapp.cdc.gov/cgi-bin/broker.exe>2002.
6. Popovic, J.R., and Hall, M.J. 1999 National Hospital
Discharge Survey. Advance Data No. 319, 2001.
7.
McGinnis, J.M., and Foege, W.H. Actual causes of
death in the United States. Journal of
the American Medical Association 270(18):2207-2212, 1993.
8.
Institute of Medicine. Appendix D: Ambulatory-care-sensitive conditions and
referral-sensitive surgeries. Access to Health Care in
America. Washington, DC: National Academy Press, 1993, 219-222.
9. U.S. Department of Health and Human Services. Leading
Health Indicators.
<http://www.healthypeople.gov/LHI/>2002.
10.
Gamm, L., and Bell, S. Identifying rural health
priorities within Healthy People 2010: A report on the results of the Rural
Healthy People 2010 survey 1. Dallas, TX: National Rural Health Association Conference, May 2001. Also see
Table 2 of this Introduction.
11.
Centers for Disease Control and Prevention. WISQARS leading causes of death
reports, 1999-2000. 2002. <http://webapp.cdc.gov/sasweb/ncipc/
leadcaus10.html>2002.
12.
Dillman, D.A. Mail and internet surveys: The
tailored design method (2nd ed.). New York, NY:
John Wiley and Sons, Inc., 2000.
13.
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.
14.
Gamm, L., and Hutchison, L. Rural health priorities
in America¾Where you stand depends on where
you sit. Journal of Rural Health
(Forthcoming, Summer 2003).
15.
Geyman, J.P.; Norris, T.E.; Hart, L.G. Textbook of
Rural Medicine. New York, NY: McGraw Hill, 2001.
16.
Loue, S., and Quill, B.E. (eds). Handbook of Rural Health.
New York, NY: Kluwer Academic/Plenum Publishers,
2001.
17.
Coburn, A.F.; Kilbreth, E.H.; Long, S.H.; et al.
Urban-rural differences in employer-based health insurance coverage of workers.
Medical Care Research and Review
55:484-496, 1998.
18. Randolph, R.;