Rural Health and Poverty Marie Florent-Carre, D.O., M.P.H. Director, Department of Rural and Urban Underserved Medicine Nova Southeastern University College of Osteopathic Medicine

Objectives Health inequities faced by rural residents How poverty impacts health in rural communities Discuss the role of literacy and educational attainment on the health of rural residents Discuss provider sustainability in rural settings

Inequities faced by rural areas Income, employment, and poverty Educational attainment and literacy Adequate community infrastructure, which can ensure public safety, allow access to media, and promote wellness Environmental health, including water quality, air quality, and pollution Access to safe and healthy homes, including issues related to energy costs and weatherization needs, lead-based paint, and other safety issues Access to affordable transportation, which can impact both job access and healthcare access Access to healthy and affordable food Access to healthcare services

Approximately 60+ million Americans live in rural America The need for increased access to care and insurance coverage is especially crucial for rural populations because they receive less preventive care and have higher rates of all chronic diseases than their urban counterparts (Bailey, 2010).

Health Disparities – Rural Population Differences in health status when compared to the general population, often characterized by indicators such as: higher incidence of disease and disability, increased mortality rates lower life expectancies.

Rural Risk Factors Rural risk factors for health disparities include: geographic isolation, lower socio-economic status, higher rates of health risk behaviors, and limited job opportunities. higher rates of chronic illness and poor overall health are found in rural communities when compared to urban populations.

Socio-economic impact Marginalised groups and vulnerable individuals are often worst affected, deprived of the information, money or access to health services that would help them prevent and treat disease. The cultural and social barriers faced by marginalised groups – including indigenous communities – can mean they use health services less. Overcrowded and poor living conditions can contribute to the spread of airborne diseases.

A meta-analysis published in the American Journal of Public Health in 2011 found that in the year 2000, 245,000 U.S. deaths were attributable to low education, 162,000 to low social support, and 133,000 to individual poverty. These social determinants have become crucial in health improvement discussions.

Close Living Quarters Rural Palm Beach

Close to Home Liberty City, a historically known, predominantly black neighborhood in Miami, has been struggling with high rates of crime and poverty for years. Disproportionate numbers of teens and young adults are the victims of gun violence, as discussed in APHA’s Nation’s Health new issue. King, associate professor in the University of Miami Public Health Sciences says that tackling the root causes – poor housing, high poverty, lack of safe outdoor spaces – will benefit overall community health.

Rural Palm Beach

National Rural Health Association Priorities The National Rural Health Association (NRHA) reviewed the draft of Healthy People 2020, and provided a general overview of the issues NRHA believes should be effectively addressed in the final report.

Access to care The need for increased access to care and insurance coverage is especially crucial for rural populations because they receive less preventive care and have higher rates of all chronic diseases than their urban counterparts (Bailey, 2010).

Health Care Services A national survey places access to quality health services as the top-ranking priority among rural health care stakeholders and leaders (Nelson & Gingrich, 2010). This is also one of the hardest obstacles to overcome in rural areas due to lack of health care providers and limited or no health insurance coverage for rural residents.

Physician shortages in rural settings Severe physician shortages exist in rural areas, and the trends are not changing enough to compensate for the demands of health services. In order to increase the number of physicians practicing in underserved rural areas, we must pinpoint the reasons physicians choose to practice in these areas and facilitate this process as much as possible from an academic or policy standpoint.

Residency Training Data shows that the majority of physicians end up in practice where they were trained and completed their residency programs (Handel & Hedges, 2007) A study by Garrison-Jakel (2010) indicate only 3 percent of new graduates will choose to practice medicine in rural or remote areas (Garrison-Jakel, 2010). Without an adequate number of health care providers available, many rural residents will remain underserved and without primary or preventative care.

Sustainability of Physicians in underserved settings Developing residency programs in the rural and underserved areas to train primary care physicians The American Academy of Family Physicians (AAFP, 2009) found physicians are more likely to practice in rural areas if: • they come from a rural background. • their specialty is in family medicine, which have longer traditions in rural communities.

Sustainability of Physicians in underserved settings • participate in the National Health Service Corps (NHSC) scholarship program which covers tuition, required fees, other education costs and a monthly stipend for up to four years. The purpose of this scholarship program is to serve health professional shortage areas (NHSC, 2010). • their medical training contains rural components to educate and expose them to rural medicine.

Health Literacy Health literacy improves knowledge and builds skills to help individuals make appropriate decisions regarding their health. In the first published study of functional health literacy in America, over one-third of English-speaking patients and 61% of Spanish-speaking patients at two public hospitals had inadequate or marginal health literacy (Williams et al., 1995).

Health Literacy Health educators stress that people of all literacy levels prefer materials that are simple and easy to understand. Health educators advocate a ‘teach back’ or ‘show me’ approach. Practitioners should also consider using non-written materials to convey important information to patients with limited health literacy, including videotapes, audiotapes or multi-media presentations.

Health Information Technology HIT has been shown to enhance physicians’ line of communication. Studies also show that HIT help increase quality of health services as well. Telemedicine considerations for specialty care Expanding communication via HIT between hospitals and outpatient clinics/community centers.

Health-in-all Policies approach A collaborative approach to improving the health of all people by incorporating health considerations into decision-making across sectors and policy areas, created by the Public Health Institute, the California Department of Public Health and APHA.

Carter Blakey, deputy director of the U. S Carter Blakey, deputy director of the U.S. office of Disease Prevention and Health Promotion, states that “…to improve health, you really have to reach beyond the traditional boundaries.”

References Agency for Healthcare Research and Quality (AHRQ). Health Care Disparities in Rural Areas: Selected Findings From the 2004 National Healthcare Disparities Report. Retrieved on October 21, 2010 from: http://www.ahrq.gov/research/ruraldisp/ruraldispar.pdf.   American Academy of Family Physicians (2009). Position Paper: Keeping Physicians In Rural Practice. Retrieved on October 18, 2010 from: http://www.aafp.org/online/en/home/policy/policies/r/fammedruralpractice.html. Bennett, KJ., Olatosi, B. & Probst, JC. (2008). Health Disparities: A Rural-Urban Chartbook. Retrieved on October 27, 2010 from: http://www.ruralhealthresearch.org/projects/100002083/.