Health on the Range: Rural Health Issues and Resources (recorded April 18, 2017)

By: National Network of Libraries of Medicine [NNLM]

- [Darlene] Thank you for joining today's webinar, Health on the Range: Rural Health Issues and Information Resources. My name is Darlene Kaskie, and I'm an outreach specialist for the National Network of Libraries and Medicine in the Greater Midwest Regional office. Before we get into the presentation, let me just start with some housekeeping items.

This session is being recorded and will be made available on the National Network of Libraries and Medicine's YouTube channel. And as you have questions throughout this presentation, please just jot them down in the chat box. And to keep the presentation moving, I will address those questions at the end of the presentation. Also, this course is available for two hours of MLA CE credit. To obtain that credit, you will complete a practice exercise and an evaluation form, and at the end of the presentation, I will give you that URL address. And I also will send it out via an email. So, I want to first thank Kate Flewelling of the MAR office, our Middle Atlantic Region office.

She was the one who originally developed this course and handed it over to me to teach. I did take some creative liberties, and I've done some changes and what with the presentation design. But the objectives do remain the same. Hopefully we'll increase your knowledge of the unique nature of rural communities, their attributes and their challenges. You should, by the end, be able to identify health information needs that are specific to rural communities. And you should be able to become familiar with resources that will address the health information needs of rural citizens. So, using the chat box, and please go ahead and use the chat box to tell me what you think of when I say rural. What is rural? And hopefully you can write in the chat box.

Any ideas of what you think of when we say rural? Okay, thank you, Deana. Small towns. Farms. Homes that are spread far apart. Any other thoughts about the word rural? A community that's not a city. Okay, towns, mm-hmm.

Health on the Range: Rural Health Issues and Resources (recorded April 18, 2017)

An area of countryside. Great. Well, we all may start out with our impressions of what rural is. And often times we have stereotypes when we think of any type of community.

And sometimes when people think of rural areas, some other words that might come to mind are that they're God-fearing and church-going, extremely conservative, or tied to the land, or individualistic or independent. Just some of those ideas. And that maybe they are just small towns, and they are just farming communities. So, stereotypes, as this quote says, has some truth to it, but you need to really understand the details of the community and find out what those characteristics are. And I wonder if you would be surprised to know that there is actually more than one definition for rural. It depends on the agency who is defining it, and what their policy and their spending objectives are. For example, the USDA, United States Department of Agriculture, defines rural, urban by a continuum code. So they distinguish metro counties by size and non-metro counties by their degree of urbanization or their proximity to a metro area.

Somewhat confusing. Next, you'll see that the Office of Management and Budget, they define rural by using the metropolitan statistical area classification, or MSA. So, MSA would one city with a population of 50,000 people or more. And an urbanized area is a population of at least 50,000. And a population of at least 100,000 for administrative purposes. And then to add to the confusion..

And to add to the confusion, we have the US Census Bureau, that defines urban and rural based on the population density of a land area. So imagine that you're flying over the landscape from an airplane. So, the more dense areas would be an urban area. And that would have a population of 50,000 people or more. And an urban cluster would have at least 2,500 people, but less than 50,000.

And then everything outside of that would be considered rural. So, there's distinct definitions for how agencies define rural. And before I continue, I'll ask you one more thing. If when you do want to add a question or some information to the chat box, go ahead and send it to all participants, and then everybody can see your questions or your comments. So, no matter how rural is defined for policy purposes, we need to look at the data available to support it.

And that's based on an aggregation of data such as the geography. So, we could look at the data at a county level, at the zip code level, or at the census track level. So, it's important to know that geographic unit has to be small enough to be able to identify all the important characteristics of a community, but not so small that there's no data available. So, according to the Rural Policy Research Institute, RPRI, counties are usually the most commonly defined geographical unit. And why is that? Well, counties typically have a very stable geographical boundary. It doesn't change very much over time.

Counties also are very important to local government. They oversee schools and hospitals, roads, your public health agencies, they collect taxes, property taxes, et cetera. Also, counties have a lot of common data. And that can be shared and used interchangeably with different agencies. So, what else does the data maps tell us about rural communities? First, rural communities vary in land size as well as population. Since the mid-1990s, population growth in rural areas has been significantly lower compared to urban or metro areas. And the gap has been widening in recent years. So, between 2006 and 2015, the rural areas fell from 0.7% to below 0%, while your metro areas only fell maybe just from 1% to 0.9%.

So, populations are decreasing in rural communities. Data also reveals that rural Americans are not homogenous, just like their urban counterparts. Rural communities have different people of ethnic backgrounds. Rural communities have refugees, and immigrants and migrants. In rural communities, not everyone is heterosexual or gender-specific. Rural areas, people either own or rent a home or an apartment. Some live in trailers or cabins.

Some people may live in RV campers or cars, because they do not have access to an actual residence. So we have homeless people in rural communities. But because rural populations are smaller in number and more spread out, it may appear that rural communities do not have the same kind of diversity, but that's deceiving. So, let's look at more specific determinants of rural communities and how these factors may affect population health.

Data reveals that rural communities are located in different geographical parts of the United States. And where they are located can impact the job opportunities available. So, in our Greater Midwest Region, we have rural populations who live in the Appalachian Mountains of Kentucky, and they work in coal mines. We have rural populations on tribal reservations up in the Dakota Plains. Casinos might be their occupation.

We have rural populations living in small towns in Indiana and Ohio, working in manufacturing plants. Rural populations in Illinois and Iowa, growing corn and soy beans on farms. We have rural populations in Michigan, Minnesota, and Wisconsin, and lake communities that might be summer resorts for tourism. So, and then we know that in all communities, including rural, there are school teachers, and health workers, and governments workers, and store clerks, and et cetera.

To find out more about a population, I recommend going to the United States Census Bureau. They collect all of the decennial information, meaning 10 years. And at the time of 2010, almost 60 million people, or about 19% of the population, lived in rural areas in the United States. Then the American Community Survey Program releases data estimates, one in five years.

So, some interesting information you would find out looking at the 2010 census is that approximately 700, well, exactly 704 counties in the United States were completely rural. And that accounts for 5.4 million people. 64% of the total rural population lived east of the Mississippi River. And then in our Greater Midwest Region, Cass County, Minnesota is the most populous rural community. Its population is 28,567 people.

And South Dakota was the most rural among our Midwest states. It has almost 43% rural. I notice in the chat box that somebody, I think it was Molly, mentioned that they, in a rural community, they may not have the same type of resources as you might find in an urban community.

And that is true. We can look at telecommunications as an example. The digital divide, if you've heard of that term, came into existence under the Obama administration. And data was revealing that the rural communities do not have the same internet infrastructure as the metro areas. The Federal Communications Commissions describes broadband, or high-speed internet, as the fixed capability to download data at 25 megabits per second and upload data at three megabytes per second. And here you can see in this map from the FCC where there is 100% broadband access, and then where there is 0%.

And there are still some areas, and they are mostly in those rural areas. And how would the disconnect affect the population and their health? Well, you might think of telehealth and telemedicine. In rural communities that are very isolated, where they may not be close to an academic teaching hospital or a critical access hospital, telemedicine would be vital. And if they do not have the high-speed internet, that may not be available to them. The Federal Communications Commission has developed a Mapping Broadband Health in America project.

I recommend coming to the site and playing with it, because you can filter broadband access speeds, and then compare it to chronic health conditions and see how it's faring. How do they compare? And that's another way to look at is there a disconnect between having high-speed internet and health outcomes. Down here in this page, you see that if the broadband access is 90%, the diabetes rate on average in the United States is 10%, almost 10%. And then if you change the statistics, you'll find other numbers to compare. Data shows that rural communities are poorer than urban communities.

In 2015, nearly 17% of the rural population was poor compared to 13% of the urban population. And contrary to common assumptions, a substantial number of poor are employed. They're just underemployed. So, underemployment accounts for approximately 45% of the total population. And here, I found some statistics to show you that difference in our Greater Midwest Region.

You will see all but Indiana, where the rural population has more unemployment than the urban areas. To find more information on unemployment, you can go to the Bureau of Labor Statistics, and they have this nice interactive map. You can click on a state, and you come up with the current as of, February's the most current data they have. In Illinois, as you see here, the unemployment rate is 5.4%.

If you click on it, the state, and if it is working properly, if I can embed it, you could actually get to the county level information as well. So, when you go to this site, you should be able to click on that state, and you'll see the county information. Looking at education, there is a divide in rural education in the population. According to the National Assessment of Adult Literacy, only 12% of adults have a proficient health literacy. So that means that one out of nine adults have the ability to manage their health and prevent disease. And you'll see in the rural areas that fewer people complete high school, and then the gap increases in post-secondary education. And to find more statistics and information about rural education, statistics, you would actually go to the National Center for Education Statistics.

It's being a little slow coming up. But they have this map. And you can filter indicators and get to the information about the different schools when you click on an area. It's still loading. It should be faster if you do directly to the internet site. I have this embedded. And it will be color-coded. So you'll see that the most rural, remote areas are green when this finishes popping up.

And then you can look at some different data about that community and those schools. And we'll move on, since it's slow. Next, let's talk about Medicaid.

When you have a large poverty base, you have more people who cannot afford health insurance or copays and deductibles. So they require Medicaid and other subsidies to help them survive, and live, and receive healthcare. And Medicaid is a health and longterm care coverage program that was enacted in 1965. And then in 1997, there was another program that was implemented called the Children's Health Insurance Program, called CHIP.

And it's to provide coverage for children in families with low income. And Medicaid and CHIP are administered by states within broad federal guidelines. So they're jointly funded between the government and the states. And you will notice here that Medicaid is slowing down in some areas. And in areas where Medicaid is not expanding, we might think of these as very rural, heavily rural population groups in those states. And yet, Medicaid is slowing down in those communities. The Kaiser Family Foundation is a consulting group, consulting firm. And they do a good job of mapping the Medicaid and C-H-I-P, the CHIP enrollments.

If you click on a state, you will see how many people are enrolled in the Medicaid and CHIP programs. In rural areas, because they are isolated and spread out, it is difficult, often, to find large teaching academic hospitals or large hospital health systems. To take care of that population group, there are critical access hospitals.

And it's been given this designation by the Centers for Medicare and Medicaid. And this is in response to trying to find healthcare for the rural populations that is spread out. So it's to reduce the financial vulnerability and improve access to healthcare in these communities. To be designated as a critical access hospital, it has to meet some criteria. Which are that there's 25 or fewer acute care inpatient beds, and it has to be located more than 35 miles from another hospital. And it has to provide an average annual length of stay of 96 hours or less for the acute care patients, and have a 24/7 emergency care facility, emergency hospital. But we know that rural hospitals are closing. More than 60 rural hospitals have closed since 2010.

So, to look and find a critical access hospital, this Flex Monitoring Team out of the combination of University of Minnesota, North Carolina, and Southern Maine has this website. And you can do a state search and locate the critical access hospitals in your region. Another health provider are the rural health clinics. In a similar way, they're also there to increase primary care, as opposed to acute care, under the Medicare and Medicaid plan. And rural health clinics have to be staffed at least 50% of the time with a practitioner, and are required to provide outpatient primary care services and some lab work.

And clinics also use nurse practitioners, and PAs, and certified nurse midwives to operate those systems. To find a rural health clinic, HRSA, the Healthcare Resources and Services Administration, is the one who designates and funds those federally assigned clinics. You can search their map, their website, and locate those rural health clinics by putting in a location, a geographical location, and deciding how many miles away you wanna look for it in that region around that area.

Then, we have the Indian Health Service. It's an operating division, which, within the US Department of Health and Human Services. And it's responsible for providing direct medical and public health to the federally recognized Native American tribes and Alaska Native people. And their goal is to raise the health status for this population group. And they provide a service for about 2.2 million American Indians. In our Midwest region, we are primarily under the Great Plains Area Office, which is in Aberdeen, South Dakota. And it works with 19 Indian Health Service units.

So, if you go to the Indian Health Service webpage, you can locate a healthcare clinic by putting an address and doing a search. And also, they also provide a lot of valuable information and resources that are directed to that population group. And then, when we look at the rural area, we have to think about climate and weather, such droughts, wind, storm, floods. All this affects population health, but more so within agricultural community.

And those kind of conditions can interrupt, disrupt crop production. Manmade farming practices also affect the environment, such runoff waste from feeder farms or pesticide use. All those chemicals can seep into ground water and rivers and contaminate drinking water. And in this photo, this is a picture of a river in New Mexico after the 2015 Gold King Mine spill. And it contaminated an area of almost 100,000 people spread out in different rural communities. So, it had wide-ranging effects on the rural community. If you wanna learn about some environmental factors that impact a community, you can go to the EPA, or United States Environmental Protection Agency, and type in a location.

Let's see if I can do one quickly. Let's see if we can find one, if that comes up. I put in Jasper County, Indiana. And you can see the various information and reports that it comes back with. So you can learn a lot of information about the air quality, water quality, climate in that community. And then when we look at rural communities, we wanna think about the health occupations of people, especially in farming communities. Looking at this picture, using your chat box, what do you think are some of the occupational, environmental health concerns? Good. Pesticides.

Getting crushed by the boxes, true. How they're stacked. They look fairly precarious, the way they're stacked on the truck.

Anything else that you see that could be an environmental or an occupational hazard to one's health? Repetitive motion injuries, yes. The bodies wear out, that's true. Working very hard. They're the long term health conditions. Well, thank you for those responses.

Other things you might think of, yeah, asthma and allergies. Very good. Skin cancer. I think of them being out in the sun, melanoma. And as you mentioned, being exposed, somebody mentioned being exposed to pesticides and chemicals.

Well, there have been some reports out there that Roundup might be contributing to increased levels of blood cancers like lymphoma and, such as lymphoma. And then other things to think about when you look at this picture, and just for consideration, think about discrimination that might create barriers for healthcare in rural population groups. For minorities, or migrants, or LGBT groups, or the disabled, or the homeless. In the rural communities, do they have the same resources and support as people living in urban areas? And what could possibly be their additional challenges to getting healthcare? Oh, language. Thank you, that's right. Do they have those resources if they are a migrant and they speak Spanish? Can they go to a health clinic where they can communicate? National Library of Medicine has a wonderful product called Tox Town.

And this was developed as an interactive tool for sharing environmental and occupational health and safety information. It is a fun tool to play with, but it also takes you to some very serious links on information about environmental factors. And I understand, I haven't played with it enough, but if you click on the farm, you might hear a goat bah or a cow moo.

And then they also link you to issues about that community. We have courses that will go into more detail about how to use Tox Town and all the great information that you can obtain from it. So, we've talked about some of the unique attributes of rural communities. How do those attributes then affect the rural health outcomes? In this picture, this is a sign that was displayed at a needle exchange program in Austin, Indiana. A couple of years ago they had a rash of HIV incidences, maybe being spread through intervenous needle sharing.

So, what are those factors? Well, we see more, as I mentioned, HIV, we see more chronic illness in rural communities. A recent report from the CDC shows that obesity and cigarette smoking are the leading causes of preventable disease and death in rural communities. And besides death, they also just, before death, they lead to health complications, such as diabetes, or congestive heart failure, or lower respiratory disease and cancer. And chronic illness puts a strain on providers as well as our services and healthcare costs. And data does show that obesity, no matter in what poverty area it seems like, across the United States, obesity is on the rise.

And especially in the rural communities. And if you think about that, do rural communities have recreational centers or safe country roads or parks to walk and get exercise? Also, in many rural communities, people might be working two or three jobs to make ends meet. Therefore, they might be taking advantage of eating fast foods or not taking the time to exercise or go for checkups. Maybe they can't get off of work. You know, if they're working a minimum wage job, and they can't get away to do preventative healthcare screenings that may contribute to chronic illness.

But to learn about different health conditions, if you were working with consumers or if you were at a community clinic, be sure to think of MedlinePlus. This is the National Library of Medicine database. It has thousands, over 900 health topics that you can get into to discuss and share with a patient about their conditions. And it leads to other resources. There's videos and tutorials that you can show to a client so they can see maybe how this surgery, if they're gonna have a prostate surgery, maybe they can get a little information and see what they can expect. And there's also a portal to drugs and supplements. There's something called the Pillbox that you can get to to get information about the drugs that a person may be taking, and they want to know the side effects.

So, MedlinePlus is an excellent source. It comes in multiple languages to decrease the barrier to language. There's also an encyclopedia, a medical encyclopedia, to get more information on articles and images. Then when we look at the rural communities, we wanna think about older adults. These communities are growing in numbers. And aging is increasing in population. Sometimes this is because younger adults leave the older communities, and they leave the older adults behind.

They call that aging in place. In rural communities, on average, we find a higher percent of 65 and older. And as you advance in age, you may need more help with skilled nursing or chronic health management. You may have more frequent medical visits, requiring these long distance drives to reach a clinic or a hospital in a rural community. And that in itself is a barrier. And think about treacherous roads during inclement weather.

So if you have a health appointment and you get a blizzard, they might miss that appointment. They might have a health condition like glaucoma or something else so that they cannot drive. And if they do not have a support system, who's there to drive them to those appointments? The National Library of Medicine has this wonderful portal called the NIHSeniorHealth, where you can get to specific information that would be of interest to your adult consumer, your older adult. The other thing that is on the uptake in rural communities is substance abuse.

There seems to be a sense of despair in rural communities that is on the increase due to many of the factors we discussed. And this may be causing an increase in mental health problems and higher incidences of substance abuse and domestic violence. Currently, drug overdose is the leading cause of accidental death in the US. And the opioid addiction has become epidemic. The Centers for Disease Control reports that over 33,000 deaths in 2015 were related to opioid overdoses, those pain killers. In 2015, the five states with the highest rates of death due to drug overdose were West Virginia, New Hampshire, Kentucky, Ohio, and Rhode Island. So, three of those states are within our Greater Midwest Region.

So, suicides, motor vehicle fatalities, and drug overdoses are some of the things that have increased in our community, in rural communities. The Substance Abuse and Mental Health Services Administration does a great job of collecting information regarding mental health and substance abuse. This is a good place to find information on treatments, such as the opioid disorder.

They have a whole webpage dedicated to that condition. So this is a good website to go to for information. And next, as we think about this, the workforce shortage in the United States in the rural areas, it's difficult, and it's a challenge to recruit providers and specialists to rural areas. So, family physicians comprise only 15% of the US outpatient physician workforce nationwide. Yet they provide 42% of the care in rural areas. So, it is harder to get to a primary care physician in a rural area compared to an urban area. And as you see here, the shortage is even greater when you look at mental health coverage.

And yet, we have an uptake in substance abuse in mental health, where we need more access to mental health services. And I touched upon the topic of substance abuse and accidental overdoses that leads to premature morbidity. Life expectancy in rural America is two years less than what it is for urban dwellers.

And for American Indian and Alaska Native people, the expectancy is 11, 11 years less. The Brookings Institute just released a paper last month, which points to a rising feeling of hopelessness and despair, as I mentioned earlier. And that's driving the decline in health and life expectancy among the working class white Americans. They call this the death of despair, because they're dying of drugs, alcohol, and suicide. So, I've touched upon different databases and resources as we've gone through talking about rural healthcare. Let's look at some other resources that are more specific just to rural healthcare, starting with the USDA, the United States Department of Agriculture.

They have this Economic Research Service, which is full of data and resources to learn more about rural health and agriculture. They take care of obesity reports, studies on food insecurity. They take care of the SNAP, or the Supplemental Nutrition Assistance Program data system.

The low income and low supermarket access data. One of the maps I wanted to show you that I find interesting, if I can get to it, is the Food Environment Atlas. If you enter this map on their website, the data is a bit dated. They go up from 2007 to 2012. But if you click on any county in the United States, and let's click on this one in Illinois that's red, it will tell you that in 2007, there was six fast food restaurants, but in 2012 it has increased to nine. So there's been more than a half a percent, or it's changed 50%, gone up. And think about how that might affect conditions such as obesity. Then, we cannot have this presentation without sharing the Rural Health Information Hub, RHIhub.

This project is funded by the Federal Office of Rural Health Policy. And it's a national clearinghouse on information, resources, technical assistance. Anything that's related to rural community health organizations and providers, and government health officials. And just a wealth of information. So, you would need to come here and explore this website. But I will show you quickly this Am I Rural? Tool.

So, if you were wanting to find out, is my city or county rural? Type it in, I have one that's preset for Jasper, Indiana. Pull it up, run the report. And you'll find some basic information.

Especially from HRSA. In this case, does it have rural health clinics? Yes. And as you go on down, you get some population from the census.

And then it talks about shortage areas. Is there a shortage of primary cares? No. Dental care is okay. But mental health, yes, there is a shortage there. So. Well, I have presented a considerable amount of information.

But I do this because we hope that it peaks your interest. And maybe you want to help engage in rural communities, and help support the National Library of Medicine's mission to help the underserved, to help communities, and get health information to them, improve their health literacy. And in order to help you engage with these communities and find partners to work on projects with, we created, or I created, this winter, something called the Underserved Health Communities Project. Using resources from many of those resources I showed you, the Census Bureau, the labor statistics, Department of Education, I compiled data on the 10, 20 counties, two counties in each state, that had the highest risk for health factors according to the county health rankings and road maps.

These counties are in the darkest shaded color, as you see here. And the ones that are highlighted in red actually have more information, more stories about them, so that if you go to that website you can engage. And I don't think it will work for my embedded website, but come to this website on our homepage, click on a story, and you will learn more about the specific factors of that community.

But if you click on any county, even if it does not have a story, you can get to the county health rankings and road maps, which is a snapshot of that community and its health factors. You could also go into the Census Bureau and get more information about the population. And we have created a little chart that shows the ethnicicity of the community. In this case, this is almost 97% white in this population in this county of Iowa. And many of the resources, the websites that I shared with you today, can be found on this website as well. When it says want to learn more, you can link to many of these websites. And some of them you can interact directly with by clicking on these tabs, such as the FCC Broadband Map. And we present this information to you, because we hope that you will want to engage in the rural health communities, as we mentioned, and will have an idea of a project that you want to have funded.

And our new funding season, year, just started. We'll begin May 1st. And here are some opportunities to apply for an award. The ones that would get priority are those underserved communities, those communities in the dark blue shade that I just showed you. And you can receive an award up to 10,000 or even up to 20,000.

Because we want to increase our outreach in those areas. So, that is what I have to present today. And now I will look at the chat box and see if there are any questions that I can address. Going up to the chat box. Language barriers. Janice said something about homeland security concerns. - [Woman] I did see, Darlene, that Janice had a question about the Indian Health Service, and whether the Indian Health Service will provide emergency care to non-Indians with acute conditions such massive heart attacks or that kind of thing.

- [Darlene] I do not know that answer. That would be a good question to look on the Indian Health Service website. I do not know for sure.

I would think not, because of the funding. But I can't speak for that for sure. I'd like to look that up and maybe get back with you, Janice, and send you that email. Any other questions? It's a lot of information.

But I wanted to give you an overview. If you do have questions later, please send me an email, and I will follow up with you. And then to conclude, in order to receive your two hours of MLA credit, I'm asking that you complete a practice exercise of five questions. And this is the URL that you will go to to complete that exercise. And with these questions you will be able to practice and use some of the resources I shared today. And if, as you're working on this practicum, please reach out to me with questions. And I will also follow up with an email to all of you who attended today and give you this URL address.

And after you complete this exercise, you will advance to our survey, and then you will receive your two hours of CE credit. So, that is all I have for today. Thank you very much for attending. And I hope that you will look forward to working with rural health communities in the future.

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