Place Matters in Determining Rural Population and Individual Health

October 10, 2016|12:14 p.m.| Anna Bartels

Geography affects health outcomes due to the mal-distribution of health and healthcare resources across different geographies; however, social determinants of health vary regionally, too. Barriers to access and social determinants of health specific to rural areas can contribute to rural disparities in health and highlight a need for place-based interventions.

“Place Matters” Highlighted at NOSORH Annual Conference

In early September, Michael Fraser, executive director of ASTHO, and Lillian Shirley, director of the Oregon Health Authority’s Public Health Division, each gave a presentation on why “place matters” to the National Organization of State Offices of Rural Health (NOSORH) during its 2016 annual meeting.

Over the past several decades, there has been a widening gap between the life expectancies of urban and rural populations: the variance in life expectancies measured 0.4 years in 1969-1971, and today the life expectancy difference has increased to 2.0 years. Currently, there are 2,157 rural Health Professional Shortage Areas, compared to 910 urban. Local health departments in micropolitan and rural areas provide higher rates of some clinical services than urban local health departments, including childhood immunizations and family planning services; however, the most rural local health departments may still be limited in their ability to respond due to few resources and capacity. Rural health departments rely more heavily on federal resources and clinical revenues relative to overall funds than urban health departments, which also contributes to more limited flexibility in spending.

In light of these disparities, Fraser pointed to the need for collaboration between public health departments and offices of rural health. For instance, the majority of state health agencies report that they engage in activities to promote access to healthcare: 94 percent report that they are engaged in health disparities and minority health initiatives, and 72 percent they are engaged with rural health initiatives. Public health must also explore how it can better support rural service delivery and rationalize the scale of health resources. Further, services must be scaled in a way that is regionally specific and culturally sensitive, in order to go beyond clinical services alone and improve population health. Fraser also noted that state innovations in telehealth and global budgets for rural hospitals also may contribute to improved access to health services and healthy places.

Shirley discussed how the concept of place-based interventions are important to rural Oregonians, since the disparities between urban and rural communities are stark. In 2016, state and local public health authorities conducted an assessment of varying foundational public health capabilities across the state. This assessment found that over one-third of Oregon communities, many of which are rural communities, have only limited or minimal foundational public health programs. These services include communicable disease control, prevention and health promotion, environmental public health, and linkages to clinical preventive services.

Shirley identified a key component to addressing these limitations as improved partnerships between public health and primary care systems. “Collaboration can prevent or lessen the incidence and severity of disease and injury, improve the health of our communities, and reduce the demand on our healthcare system. Knowing and understanding the strengths of our particular roles in the health system creates healthier places,” Shirley explained. This collaboration will require cross-organizational strategic planning with a common agenda and measurements, mutually reinforcing activities, and continuous communication and evaluation, she added.

In Oregon, for example, public health and primary care stakeholders have identified several shared outcomes and their own role. Public health and primary care are working together to advance health promotion policies and practices, such as access to healthy foods and tobacco-free living spaces, where public health can monitor the health needs and risk factors of geographic populations and primary care can monitor and address risk factors for individuals. Further, both can collaborate to provide health consultation and resources for the entire community. Public health activities in support of this common goal may draw primarily on epidemiological, demographic, and economic data, whereas primary care activities would draw from medical science and individual patient history.

Addressing Rural Health Disparities through Public Health and Primary Care Integration

The Integration Forum has explored mechanisms to improve primary care and public health collaboration with the aim of improving population health and lowering healthcare costs. On Sept. 30, the Integration Forum Workforce Committee was joined by Michael Meit, co-director of the NORC Walsh Center for Rural Health Analysis, to also discuss rural health disparities through the lens of social determinants of health.  

The majority of persistent poverty counties, which are defined by having a poverty rate of at least 20 percent in each of the U.S. censuses, are rural counties. Further, the median 2013 household income for rural counties was $42,628, compared to $52,204 in urban counties, and the average percentage of rural children living in poverty is 26 percent versus 21 percent urban. Poverty is one of the greatest determinants of health status, along with factors such as education, social and community stability, access to healthcare services, and environmental factors. The resulting health outcomes are illustrated in detail in the Walsh Center’s 2014 Update of the Rural-Urban Chartbook, which suggests that rural disparities have remained, and in some cases grown, in terms of health status (e.g. smoking, obesity, and suicide) and access (e.g. physician supply) over the past decade, even as the nation’s health has generally improved as a whole.

Meit also highlighted a collection of Evidence-Based Toolkits for Rural Community Health, which provide step-by-step guides to addressing care coordination, community health workers, health promotion and disease prevention, mental health and substance use, obesity prevention, oral health, and services integration. Each toolkit’s resources can be adapted to fit local communities and specific populations served.

Place matters, and place matters for rural health, because geography has become a reliable predictor of health and because context shapes ideas about and access to healthy lifestyles. Health inequities in rural communities contribute to a lifetime of health and economic challenges that affect both the individual and the community as a whole. Efforts to improve the distribution of health resources are growing and will continue to be bolstered by public health-primary care partnerships. However, nontraditional and place-based collaborations to address the broader socioeconomic disparities will also be needed in order to truly improve rural health. A concluding remark in a presentation by Place Matters Oregon sums it up well: “When we make better places, we build better lives.”

Anna Bartels

Anna Bartels is an analyst for health systems transformation at ASTHO, where she supports the Integration Forum’s activities and projects related to payment and delivery reform.