Rural Populations and Health

Determinants, Disparities, and Solutions

Richard Crosby, Monica L. Wendel, Robin C. Vanderpool, Baretta R. Casey

• Editorial: Jossey-Bass
• Año: 2012
• ISBN:
  9781118235485
• Edición: 1
• Categoría: Medicine
• Categoría: Public Health, Administration & Care

Health-related disparities remain a persistent, serious problem across the nation's more than 60 million rural residents. Rural Populations and Health provides an overview of the critical issues surrounding rural health and offers a strong theoretical and evidence-based rationale for rectifying rural health disparities in the United States.

This edited collection includes a comprehensive examination of myriad issues in rural health and rural health care services, as well as a road map for reducing disparities, building capacity and collaboration, and applying prevention research in rural areas. This textbook offers a review of rural health systems in Colorado, Kentucky, Alabama, and Iowa, and features contributions from key leaders in rural public health throughout the United States.

Rural Populations and Health examines vital health issues such as:

• Health assessment
• Strategies for building rural coalitions
• Promoting rural adolescent health
• Rural food disparities
• Promoting oral health in rural areas
• Physical activity in rural communities
• Preventing farm-related injuries
• Addressing mental health issues
• Cancer prevention and control in rural communities
• Reducing rural tobacco use

Rural Populations and Health is an important resource for students, faculty, and researchers in public health, preventive medicine, public health nursing, social work, and sociology.

Part One

Rural Communities in Context

Chapter 1

Understanding Rural America

A Public Health Perspective

Richard A. Crosby

Monica L. Wendel

Robin C. Vanderpool

Baretta R. Casey

Laurel A. Mills

Learning Objectives

• Understand the unique aspects of rural America and the key contextual influences on rural public health.
• Identify key determinants of rural health disparities in the United States.
• List and explain eight major influences on rural health disparities.
• Compare and contrast rural health disparities to those experienced in urban and suburban areas of the United States.

•••

Covering about two-thirds of the land in the United States, rural America is extremely diverse. The diversity found there exists as a function of rich cultural traditions handed down from generation to generation as well as from adaptations to the environment and the livelihood it supports. Thus, it is indeed important to know that term rural America is far too vague to have any practical value in this book. Instead, rural America should be thought of as a tapestry of rural cultures—shaped by geography and tradition—that spans from the rural poverty of the Mississippi Delta to the rural isolation of states like Montana and Wyoming. Rural life, and the associated challenges to public health, is therefore difficult to describe in a single chapter. Recognizing this, we urge you to remain mindful about this tapestry as you read this chapter, which by necessity will need to broadly describe rural America and its public health issues. Please also bear in mind that rural is not just a place. Instead, the term represents a culture of rural people who typically have tight-knit communities, strong ties to the land they live on, and a long history of shared life experiences. Despite the poverty that often characterizes rural areas, the isolation of rural places, and the growing digital divide that places rural Americans at a disadvantage in many ways, rural people may commonly perceive their lives to be of very high quality mainly because of their strong sense of community, extended families (most of whom may never leave the community), and an aesthetic beauty offered by life largely unspoiled from the trappings of urban settings.

People in rural areas of the United States do have a great deal in common: a strong sense of independence, pride in their community, and self-reliance. Although these qualities can be valuable assets to public health programs, they can also be obstacles that prove difficult to overcome. As an example of using rural assets to advance a public health agenda, consider the case of southeastern Kentucky, where a cervical cancer program known as Faith Moves Mountains (FMM) has been used to successfully promote and increase Pap testing among medically underserved women living in a high-incidence area for cervical cancer (see Chapter Nineteen) (Schoenberg et al., 2009). The program works through key community stakeholders—women who are well connected throughout the community. These women conduct educational sessions in churches and subsequently navigate women into screening for cervical cancer. In this rural culture (as is common in rural America), churches are a focal point of communities, serving as a mechanism for the creation and maintenance of social capital. Social capital can be thought of as sense of cooperation, reciprocity, and trust among community members (Putnam, 2000). As such, social capital is widely recognized as one the principle factors in any organized effort to promote public health (Kreuter & Lezin, in press). The FMM program tapped into this local source of social capital, thereby using the asset of the rural tight-knit community as a method of diffusing innovations (e.g., Pap testing) in public health. The FMM investigators are now extending their successful faith-based approach to improve eating and exercise behaviors of community residents as well as to achieve reductions in tobacco use. At its heart, FMM is about using rural social capital to catalyze the adoption of health-protective behaviors among people otherwise at-risk of morbidity and early mortality.

Rural “assets” can also be a barrier to public health efforts. For example, in many of the tight-knit rural communities across the United States, a sense of independence can be taken to the level of actively avoiding assistance from people who are not part of the community. In these modern times, this pioneer mentality can be quite limiting in terms of public health. In the absence of outside assistance, residents may create alternative beliefs and practices regarding health and healing. A rural community that is resistant to outside influences thus becomes figuratively isolated from the diffusion of public health innovations such as improved dietary practices, screenings for the early detection of cancer, cholesterol-lowering drugs, occupational safety measures, the use of contraceptives, cervical cancer vaccines, the use of infant car seats, and improved dental hygiene practices.

A Few Basic Principles

In addition to understanding the concept of rural assets, we urge you to keep the following principle in mind: geography is critical—it shapes culture and practices of people. In many ways, geography determines something that scholars have termed context (Phillips & McLeroy, 2004). Context includes infrastructures such as roads and bridges, social structures such as community leadership and key opinion leaders, physical topography such as mountains and deserts, and community structures such as common values and history. Rural health disparities are often an outgrowth of contextual issues. For example, consider a typical rural Appalachian community set in steep mountains that are far too covered in timber and rocks to build roads on. Consequently, the roads are all built in between the mountains; these narrow valleys are called hollers. Hollers are the same places that rainwater runoff filters into creeks. People build their homes (or place their mobile homes) in the hollers because the cost of doing so is far less expensive than building on mountain sides. Building in the hollers also prevents the concern of not being able to get off the mountain at times of inclement weather from late autumn to early spring. A holler may house several extended families in thirty or more dwellings. In the spring, hollers are prone to flooding and the low-lying homes can be damaged or even swept away. In the winter, driving out of the hollers into the steep mountains may be impossible because of snow and ice. This same geography does not support farming, so people are forced to travel to towns or cities for gainful employment or work literally within the mountains as coal miners. As you can imagine, the geography described in this brief example has a profound influence on the context of rural life in Appalachia.

It is also important to understand that rural cultures’ interactions with race and ethnicity have a profound influence on public health. This is known as composition (Phillips & McLeroy, 2004). In essence, the disadvantages that US minority members so often experience are compounded by the disadvantages created by the lack of employment and educational opportunities in rural areas as well as historical policies such as slavery and the creation of Indian reservations. Indeed, minorities in the rural parts of the United States have been referred to as a forgotten population (Probst et al., 2004).

Finally, as you read this chapter (and this entire book), please understand that health care and public health are two very different concepts. Public health is about prevention and its focus is always on entire populations. An all-too-frequently-held belief is that health care is the key to improving the health of the public. In actuality, this idea is arguably false. Ample evidence suggests that the key to improving public health lies in reversing the actual causes of death such as tobacco use, overeating, sedentary living, alcohol use, and other behaviors that lead to morbidity and early mortality (Farley & Cohen, 2005; Mokdad et al., 2004). Thus, we will use the phrase rural public health to represent the combined efforts to prevent the actual causes of disease and death (behaviors and environmentally driven causes) as well as issues pertaining to a lack of health care. The combination of prevention approaches and health care improvements are the very reasons we decided to create this textbook. Indeed, this is the first book to take this combined approach to rural public health. Unfortunately, despite a great deal of published papers on public health very little attention has been devoted to rural public health. As suggested by Phillips and McLeroy (2004) rural public health focuses on reducing population morbidity and mortality through multilevel, tailored, prevention efforts (primary, secondary, and tertiary) accounting for the unique context and composition of rural communities. Rural public health also takes an ecological perspective, meaning that the prevention approach works within the context of families, communities, culture, societal norms, and public policy.

An Overview

Galambos argued that rural health disparities have been a “neglected frontier.” This reality is indeed unfortunate given that significant numbers of people live in rural areas (Galambos, 2005). Depending on how rural is defined, the total rural population accounts for between 10 and 28 percent of the entire US population (Hart, Larson, & Lishner, 2005); however, the land mass occupied by rural residents is approximately twice that occupied by urban residents.

This book is dedicated to the illumination of public health issues and challenges for this often-neglected population of Americans. In this chapter, you will learn about eight key factors that profoundly influence disparities in rural public health. We will then provide you with key principles that can be applied to improving rural public health. Throughout the chapter, we will provide you with case studies, vignettes, visual displays, and photographs designed to help you learn the concepts easily. Chapter One is an overview and many of the concepts you learn in this chapter will be discussed in subsequent chapters to aid the learning process. Chapter Two is then quite specific as it describes various systems of measuring rurality (what constitutes being rural) in the United States. Chapter Three then provides a succinct history of rural public health and further elaborates on a few of the concepts introduced in Chapter One. Chapter Four expands on the concept of overlapping disparities by describing the problems and issues faced by rural minorities. With these four chapters firmly behind you, the book then introduces the concept of rural public health systems, including health policy and efforts directed toward population-level change. After an introduction to rural public health systems (Chapter Five) you will learn about these concepts by reading chapters focused on specific rural states: Colorado (Chapter Six), Kentucky (Chapter Seven), Alabama (Chapter Eight), and Iowa (Chapter Nine). You will then be ready to learn about three key skills in conducting activities toward improving rural public health: (1) assessment (Chapter Ten), (2) coalition building in rural areas (Chapter Eleven), and (3) capacity building in rural areas (Chapters Twelve). The book will finally take you through a series of applied chapters (Chapters Thirteen through Twenty), each devoted to specific health issues such as adolescent health, food disparities, oral health, physical activity, farm injuries, mental health, cancer prevention and control, and tobacco prevention.

Eight Key Factors

Understanding rural public health requires that you first understand some key factors that influence this broad construct. In essence, any given rural community can be said to possess certain characteristics that affect its ability to promote and maintain health. A spidergram is a simple way of providing a snapshot of all factors of such a complex idea at one time. Each factor in a spidergram is represented as a “leg” of a spider, with incremental measures along its axis. In this instance, factors associated with a rural commu­nity’s ability to improve and maintain public health is the purpose of...