Course #300

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Hours
8
$32.95

Course Material Valid Through
March 2023

Rural Nursing: Healthcare Delivery and Practice Issues

Disclosures

Description

Author: Angeline Bushy, PhD, RN, FAAN

This continuing education (CE) offering highlights health care concerns and features of health professional practice, nurses in particular in the rural context.

Learning outcomes include:

  • Define urban, suburban, rural, frontier, farm, non-farm, metropolitan, nonmetropolitan.
  • Describe residency on a continuum ranging from farm residency to metropolitan.
  • Examine social and physical determinants that can impact the rural lifestyle.

Criteria for Successful Completion

After reading the material, complete the online evaluation. If you have a Florida nursing license or an electrology license you must also complete the multiple choice test online with a score of 70% or better. Upon completion of the requirements you may immediately print your CE certificate of completion.

Accreditation

  • American Nurses Credentialing Center's Commission on Accreditation (ANCC)
  • California Board of Registered Nursing Provider No. CEP 1704.
  • This course has been approved by the Florida Board of Nursing No. 50-1408.
  • Kentucky Board of Nursing Provider No. 7­0031-12-21

Conflicts of Interest

No conflict of interest exists for any individual in a position to control the content of the educational activity.

Expiration Date

This course expires March 31, 2023.

About the Author

Dr. Angeline Bushy, PhD, RN, FAAN is the Bert Fish Endowed Chair, University of Central Florida, College of Nursing. She has practiced in a variety of rural health care settings including the community, acute care settings and educational settings. She has published extensively, including textbooks, and presented various aspects of rural healthcare delivery at numerous national and international conferences.

Purpose and Goals

This continuing education (CE) offering highlights health care concerns and features of health professional practice, nurses in particular in the rural context.

Learning Outcomes

Upon completing this continuing education course, the learner will be able to:

  1. Define urban, suburban, rural, frontier, farm, non-farm, metropolitan, nonmetropolitan.
  2. Describe residency on a continuum ranging from farm residency to metropolitan.
  3. Examine social and physical determinants that can impact the rural lifestyle.
  4. List factors that can influence the health of rural residents and their care seeking behaviors.
  5. Discuss rural factors that impact accessibility, affordability, availability and acceptability of healthcare services.
  6. Identify characteristics that are common to residency in a small rural community.
  7. Highlight characteristics of Health Professional Shortage Areas (HPSA's).
  8. Identify federal legislation that specifically focuses on rural healthcare delivery.
  9. Examine features of nursing practice in rural medically underserved areas.
  10. Compare rural professional practice with practice in a more populated setting.
  11. Examine challenges and opportunities of living and working as a health professional in rural environments.
  12. Characterize case management in a rural setting with an elderly client.
  13. Highlight the development of a rural professional-community partnership.

Background

According to the US Census Bureau, about 20%, or one fifth of all Americans reside in rural communities. At least 21 states have more than 60% of their counties designated as rural. Concomitantly, concerns regarding the provision of healthcare services to rural communities has become a national concern, especially in medical and health professional underserved regions. In other words, rural concerns focus on geographical regions that do not have an adequate number of healthcare providers and services. Policy developers are somewhat aware of the challenges in the recruitment and retention of qualified health professionals to practice in those settings. In the past decade more information became available on the nature, challenges, problems and opportunities of professional practice in geographically large and sparsely populated regions.

Historically, care of the sick in a small community was mostly provided by informal social support systems. Along with self-care behaviors, informal support systems included women in the extended family, neighbors, indigenous and ethnic healers. When informal care providers were not effective, health care was obtained from a physician who probably was located a great distance from the family's residence. Overall, the healthcare needs of rural citizens probably is similar to urban residents but, still somewhat different. For instance, in rural areas one encounters the persistent inequitable (maldistribution) of health professionals, poverty, limited access to services, lack of education and social neglect across generations. These characteristics sometimes are states as determinants of health.

Determinants of Health

Social determinants of health are conditions into which a person is born, lives, learns, works, plays, worships, and ages. These determinants can affect a wide range of lifestyle risks, functioning, quality-of-life, and health outcomes. These determinants in various environments and settings (e.g., school, church, workplace, and neighborhood) sometimes are referred to as "place." The physical determinants (i.e., attributes) of "place," can influence residents; patterns of social engagement, sense of security and well-being. Access to healthcare significantly influences a population's health status and outcomes. Examples of resources associated with determinants of health include safe and affordable housing, access to education, public safety, healthy foods, emergency care and health promotion. The relationship between the manner in which a population experience "place" and its impact health status is fundamental to understanding determinants of health which includes social and physical factors:

Social determinants include:

  • Access to educational, economic, and job opportunities
  • Availability of resources to meet daily needs (e.g., safe housing and local food markets)
  • Access to health care services
  • Quality of education and job training
  • Availability of community resources that support opportunities for recreational and leisure-time activities
  • Transportation options
  • Public safety
  • Social support
  • Social norms, attitudes (e.g., religiosity, discrimination, racism, distrust of government)
  • Exposure to crime, violence, and social disorder (e.g., presence of trash; lack of community cooperation)
  • Socioeconomic conditions (e.g., concentrated poverty, employment opportunities)
  • Residential segregation
  • Language/Literacy
  • Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
  • Cultural beliefs and values

Physical determinants include:

  • Natural environment (green spaces, weather, recreational opportunities, safety)
  • Built environment (buildings, sidewalks, bike lanes, roads, air quality)
  • Worksites, schools, recreational settings
  • Housing, community design
  • Exposure to toxic substances, physical hazards
  • Physical barriers (especially for people with disabilities)
  • Aesthetic elements (e.g., lighting, benches, building codes, facades)

Policies that positively influence social and economic conditions can improve health for large numbers of people (i.e., populations), specifically in rural settings. Improving the conditions in which rural residents live, learn, work, recreate and socialize can create a healthier population, society, and workforce. Healthy People https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

What is Rural?

What is rural? https://www.ruralhealthinfo.org/topics/what-is-rural A commonly accepted definition for rural does not exist. In fact, "rural" has different meanings to different people.

"The U.S. Census Bureau defines rural as what is not urban—that is, after defining individual urban areas, rural is what is left."

In December 2016, the U.S. Census Bureau released an 8-page document on defining rural. It describes how they define urban, then states that rural is "everything not urban".

 
urban, not rural

Figure 1

They go on to note that other federal agencies and researchers use different definitions.

Diverse and sometimes conflicting definitions is a concern for policymakers, healthcare providers as well as researchers. Imprecise definitions hinder understanding the demographics, epidemiology as well as rural health care challenges. The federal Office of Rural Health Policy (ORHP) is focused on developing consistent and meaningful definitions that characterize rural compared to urban contextual factors. In the next few paragraphs geographic and population factors along with subjective perceptions are used to distinguish rural from urban.

Remote and Sparse Population

Several more popular definitions for rural include geographic size relative to population (i.e., density); or, number of people living within a square mile. Elected officials and program developers refer to the terms, metropolitan and nonmetropolitan. A metropolitan area is defined as a city or two adjacent cities having a total population of 50,000 or more residents. Using these criteria, about 80% of the total population in the US reside in a metropolitan area and about 20% live in a non-metropolitan area.

Another set of definitions distinguishes between urban, rural, and farm residency. This definition rural refers to a community that has fewer than 2500 residents as rural; and, any community having a greater population is categorized as urban. Using this definition, of the total US population approximately 23% live in a rural area; and, fewer than 5% live in towns of this size. Less than 2% of the US population lives on a farm. US Department of Agriculture (USDA, 2019). https://www.nal.usda.gov/ric/what-is-rural

Yet other definitions categorize urban, rural and frontier regions. In this definition urban refers to an area having more than 100 people per square mile; rural refers to areas having less than 99 people per square mile; while, frontier refers to regions having fewer than six people per square mile. In some ways this set of definitions allows one to better understand the lifestyle and challenges of individuals who live in a very large geographical area. (USDA, 2019). https://www.nal.usda.gov/ric/what-is-rural

Subjective Perceptions of Rural

Policy developers, health professional educators and consumers also have their own perception as to what is rural versus urban. Some suggest rural factors are related to distance and/or time that it takes for an individual to commute to a healthcare service(s) or medical provider. For example, requiring more than 30 minutes, or having to drive more than 20 miles to see a doctor, or hospital or emergency service. However, the element of "time to service" may also be a factor for residents who live in the inner city or in a suburban area who must use public transportation; or, in situations where one encounters heavy traffic to commute to a healthcare service/provider.

 

Did you know?

  • There are conflicting views and definitions of rural as opposed to urban.
  • There is wide diversity in rural environments across the 50 states.
  • There is disagreement as to whether rural is a specialty area of nursing practice.
  • "Expert generalists" are the most successful rural health care providers who care for a variety of diagnoses in patients across the life span. For some rural residents, it may take more than a 30 minute commute to access primary health care; and, sometimes several hours to access emergency care services.

To most people "rural" is a subjective "state of mind" based on personal experiences in one's youth. For instance, for the more affluent, rural suggests a resort community in the mountains or residency in lake country. For the less fortunate, rural may suggest grim scenes such as impoverished Indian reservations that equate with Third World countries. Or, photos of migrant labor camps with one room shanties that shelter two or more farmworker families, lacking safe sanitation and potable water along with exposure to highly carcinogenic herbicides or pesticides. Or, "boom towns" that spring up overnight in energy-rich geographical regions (e.g., coal, oil, minerals). Small towns generally do not have the public infrastructures and social services to contend with the sudden influx of diverse newcomers to live and work for a short period of time in the energy or food production industries.

There is no "typical" rural town attributable to wide population and geographic diversity. For example, rural towns in Illinois are quite different from those in Washington, or Vermont, or Oklahoma, or Nevada, or Alabama or Kentucky. Likewise, there can be wide variations among towns within one state, especially communities located a larger state such as Texas, or Montana or California. All in all, most health professionals, policymakers and researchers often integrate personal experiences when interpreting the nature and complexity of rural in comparison to urban.

Economic Structures

Another classification for rural is based on predominant economic industries in the community. The US Department of Agriculture (USDA) identifies seven predominant industries to characterize nonmetropolitan regions, specifically farming dependent, manufacturing dependent, mining dependent, specialized government, persistent poverty, federal lands, and retirement areas. Each economic category also has certain demographic features. For example, manufacturing dependent communities are characterized by a large denser population, a higher proportion of female head of household and African Americans. Farming dependent communities are characterized by few persons per square mile, fewer households with female head of households, and a high proportion of elderly persons. https://www.ers.usda.gov/data-products/ag-and-food-statistics-charting-the-essentials/rural-economy/

Along with demographics, differentiating in terms of economic structures can inform about social determinants that can impact the population's health status. Economic structures contribute to predominate health problems and medical diagnoses one can expect to see in these communities (e.g., chronic illnesses, trauma associated with occupational and environmental health risks). Economic classifications, however, can lead to generalizations with little consideration be given to subpopulations (underrepresented or vulnerable groups) who in the community.

Diversity

Contributing to the problem of an imprecise definition of rural are the numerous subgroups that live and work in rural environments across the 50 states. Anthropologists report that within the major population (i.e., community) there often exists a wide range of lifestyles among various subgroups within the larger population or community. We do not know much about rural residents in general; and, even less about the numerous subgroups who coexist in these communities. To reiterate there is wide diversity from one rural community to other rural communities. In general, most available health-related information about rural populations focuses on maternal, infant and elderly populations. The Office of Occupational Safety and Health Administration (OSHA) collects and disseminates data associated with injuries in high risk industries. Hence, occupational related health information is more readily accessible. Awareness contributes to public and policy support for certain issues. However, information is sparse regarding vulnerable minority populations and families' healthcare needs and preferences.

Rural-Urban: A Continuum

Perhaps the best approach to be rural and urban is as a continuum; i.e., from remote farm residency, to a small-town, to a midsize community, to suburbia, to a large metropolis. Essentially, the various terms and concepts used by people to understand rural residency are relative in nature. For instance, small communities with no more than 20,000 population have some features that one expects to find in a large city. Then again, residents who live in a community with a population of less than 2000 often perceive a community having a population of 5000 to 10,000 residents as a "city". The smaller sized city may be where individuals and families seek healthcare and social services. As for communities that may seem geographically remote on a map, residents who live there probably do not feel isolated, believing they are within easy reach of services in urban settings. Geographic isolation is countered by communication technology and dependable transportation to a service or provider – albeit 50-100 miles from one's home.

Definitions In this Continuing Education Course

For this continuing education offering rural refers to areas having fewer than 99 persons per square mile; or, communities having a population of fewer than 10,000 people. Other terms used interchangeably herein include client/patient; health professional(s)/healthcare provider(s)/nurse (s); healthcare agency/healthcare institutions; vulnerable population/at-risk population; and, community/populations.

 

Did you know?

  • 64.4 percent of the total rural population lives east of the Mississippi River.
  • Only 10 percent of the total population in the West region live in rural areas
  • Nearly half (46.7 percent) of all people living in rural areas are in the South region

Demographics

Adding to the confusion associated with imprecise definitions of rural (as opposed to urban) are the health-related needs of the numerous underrepresented groups (minorities; subgroups) who reside across the 50 states. There is little documented on the special needs and health status of the multiple rural subgroups. Anthropologists are quick to point out that within the predominant group, there exist a wide range of lifestyles; ranging from the most provincial individual to the most culturally integrated person. Even the smallest and most remote town or village, one may find a subgroup that has vastly different lifestyle behaviors, cultural values, beliefs regarding health, illness and care seeking behaviors. Lifestyle behaviors of minority or vulnerable populations, in turn, contribute to health risks and diagnoses may differ from those of the predominant cultural. The next section of this continuing education course highlights rural and urban population demographic characteristics including age, race, marital status, education, socioeconomic and overall health status. However, it is important to stress, given low numbers, data about rural populations in general (especially subgroups) may consist of anecdotal reports rather than precise morbidity and mortality data. https://gis-portal.data.census.gov/arcgis/apps/MapSeries/index.html?appid=7a41374f6b03456e9d138cb014711e01#map

Age

Demographically, rural communities generally can be described as "bipolar" in age distribution; having a high number of younger and older residents. In other words, one can expect to find a more people between the ages of six and 17 and over the age of 65 in a rural community compared to an urban community. More specifically, persons between the ages of 25 years to 54 years account for about 38% of the rural population compared with metropolitan (43%). Roughly, about 1/5 of the rural population (20%) is between 6 to 17 years of age compared to metropolitan counterparts in that age group (17%). Of the rural population, a greater percentage (17.5%) is age 65 or older compared to the metropolitan counterparts (13.8%).

 
population size and percent 65 years and older

Population size and percentage 65 years and over by rural and urban status

Figure 2

Race

Interestingly, in most nonmetropolitan communities there tends to be a higher proportion of Caucasians (82%) compared to metropolitan communities (62%). It is important to emphasize, there are wide regional variations in the racial makeup of a region. Some rural counties have a high proportion of minorities including African Americans, Asians and Native American/Alaska Natives. Some rural communities have had an influx of relocated foreign immigrants and refugees. https://gis-portal.data.census.gov/arcgis/apps/MapSeries/index.html?appid=7a41374f6b03456e9d138cb014711e01#map

Marital Status

Individuals over 18 years living in rural areas are more likely to be or have been married than urban adults. Rural also are more likely to be widowed. Among persons over the age of 16 years living in rural areas, a smaller proportion have never been married (17%) compared to metropolitan areas (25%). Almost two thirds of the adult rural population were married (65%) compared to metropolitan (59%).

Education

While there are geographical variations, adults in rural areas have had fewer years of higher schooling than do urban adults. Of all rural, about 50% had 12 or less years of education compared to metropolitan adults (38%). Of adults completing more than high school, rural adults have considerably fewer (50%) completing some years of college compared to metropolitan adults (62%).

 
Educational attainment for adults 25 and older in rural and urban areas

Educational attainment for adults 25 and older in rural and urban areas

Figure 3

Socioeconomic Factors

In recent decades poverty increased, with racial minorities experiencing a higher rate compared to Caucasian counterparts. Compared to urban, rural residents have a greater poverty rate; and, the rural population has a higher proportion of working poor. Nearly half of all rural families live below the property index. A high proportion of rural children are poverty-stricken, especially those in minority groups (Native Americans, Native Alaskans, Native Hawaiians, African Americans, Asians, Mexican American). While minority children represent only 20% of the rural population, they experience poverty to an even greater degree than Caucasian counterparts. The poverty rate for rural children (26%) is significantly higher compared to metropolitan children (17%).

Impoverished rural children are more likely to live in substandard housing, have inadequate nutrition, unsafe drinking water, poor sanitation with limited access to public health and pediatric medical services. They are less likely to have adequate and timely immunizations, health screenings, health promoting education and anticipatory guidance. Consistent with educational level (i.e., an indicator for socioeconomic status) a substantially smaller percentage of rural families (24%) are at the high-end of the income scale compared to metropolitan families (35%).

Health Insurance Coverage

Those who are poor are more likely to be less healthy and report having more illnesses compared to counterparts who "have enough money to live a decent life". Compared to urban, rural communities have a disproportionate segment of families who are below the federal poverty level with less access to health-related resources. Level of income is an important factor as to whether the family has health insurance or qualifies for public assistance insurance (i.e. Medicaid; Children's Health Insurance Program [CHIP]). Depressed local economies also impact the health status of the community of the whole, as well as the individuals and families who live there. Unemployment and underemployment, another characteristic in many rural communities, contributes to many families not being able to afford the cost of health insurance coverage; thus, being uninsured or underinsured, which impacts health care seeking behaviors.

About half of the uninsured and underinsured live in non-urban areas. Rural families are less likely to have private insurance and are more likely to have public assistance or to be uninsured. The working poor, of which there is a high number in rural areas, are particularly at risk for being underinsured or uninsured. The descriptor "working poor", refers to adults who are gainfully employed (sometimes holding more than one job) but do not have health insurance benefits. Likewise, they do not have adequate financial resources to purchase private health care insurance. Moreover, their annual income level disqualifies them for obtaining public assistance (i.e., Medicaid, CHIP, Supplemental Nutrition Assistance Program [SNAP], etc.).

Healthy People: Rural Focused Objectives

Healthy People objectives have important implications for rural populations. A significant number of at-risk vulnerable populations who live and work in rural areas are specifically mentioned in this policy guiding document. Most states have a corresponding State Health plan that reflects Healthy People objectives. The state plan uses morbidity and mortality data to prioritize target populations with a significant health risk or diagnosis (i.e., adolescent suicide, low immunization rates among children or older adults, adolescent pregnancies, hypertension). Both the federal and state Healthy People objectives emphasize health promotion, health promoting lifestyle behaviors, prevention of chronic health problems and personal responsibility for health. However, depending on the proportion of rural residents, not every state's health plan includes objectives focusing on rural issues.

A comprehensive discussion of the rural concerns of each of the 50 states is beyond the scope of this continuing education course. The learner is encouraged to access the website of your state Department of Health and review its state health plan. Compare the Healthy People objectives included in this course with the allocated resources in your state to address relevant State Health People objectives. Next, check out your county health department's website. Identify priority objectives that reflect your state health plan and Healthy People objectives.

Health Status of Rural Populations: An Overview

Demographically and health wise there is wide diversity among and within rural communities and an extensive discussion of each community is not possible in this continuing education program. Associated with a very low population in rural areas, health related data may be lacking and imprecise (i.e., very low sample size). However, the next section discusses a general "snapshot" of rural residents' health status across the United States (US). https://www.ruralhealthinfo.org/topics/rural-health-disparities

https://ruralhealth.und.edu/projects/health-reform-policy-research-center/rural-urban-mortality

According to the Centers for Disease Control and Prevention (CDC), rural areas have higher rates for heart disease, cancer, unintentional injury (including vehicle accidents and opioid overdoses), chronic lower respiratory disease, and stroke; the five leading causes of death in the United States.

 
Percentage of potentially excess deaths among persons aged < 80 years

Percentage of potentially excess deaths* among persons aged < 80 years for five leading causes of death in nonmetropolitan and metropolitan areas† — National Vital Statistics System, United States, 2014

* For each age group and cause, the death rates of the three states with the lowest rates during 2008−2010 (benchmark states) were averaged to produce benchmark rates. Potentially excess deaths were defined as deaths among persons aged < 80 years in excess of the number that would be expected if the age-specific death rates of the benchmark states occurred across all states.

† Nonmetropolitan and metropolitan areas were identified using the Office of Management and Budget's 2013 county-based classification scheme. (Source: Office of Management and Budget, White House. Revised delineations of metropolitan statistical areas, micropolitan statistical areas, and combined statistical areas, and guidance on uses of the delineations of these areas. Washington, DC: Office of Management and Budget; 2013.

Figure 4

Socio-demographic factors and other social determinants are associated with the rural-urban gap in excess deaths from the five leading causes. Residents of rural areas tend to be older, poorer, and sicker than urban counterparts. A higher proportion of the rural U.S. population reports limited physical activity because of chronic conditions than urban populations. Lifestyle behaviors also impact mortality rates, contributing to approximately half of the excess deaths.

Potentially excess deaths (also described as potentially preventable deaths) are defined as deaths among persons aged <80 years in excess of the number that would be expected if the death rates for each cause were equivalent across all states to those that occurred among the three states with the lowest rates. Although not all potentially excess deaths can be prevented, many might represent deaths that could be prevented through improved public health programs that support healthier behaviors and neighborhoods and better access to health care services. https://www.cdc.gov/mmwr/volumes/66/ss/ss6602a1.htm?s_cid=ss6602a1_w

Some health conditions are uniquely rural associated with "high risk" industries including timber, agriculture, fishing and mining. For instance, associated with agriculture and mining are occupational – related trauma injuries, certain types of cancer and respiratory conditions associated with exposure to environmental toxins, pesticides environmental particulates.

Mental illness and stress related diseases also are prevalent in some rural settings. Economic challenges, for instance, is evident the predominant industry (sometimes the only industry) in the region. During an economic downturn there often is a corresponding rate of unemployment among residents. Economic changes not only contribute to an individual's stress level but is also reflected among family members and within the community. In a high stressed community, coping skills are evidence across the lifespan in the increased use of drugs and alcohol, interpersonal violence and suicide.

Minorities in rural communities including Native Americans, native Alaskans, native Hawaiians, migrant workers, African Americans, and the homeless have their own set of health problems. Unfortunately for most of these smaller populations little is known about their lifestyle and health risk behaviors. Partly, lack of information stems from low numbers making it difficult to quantify in population morbidity and mortality rates. Essentially, Healthy People specifies a rural access disparity to basic healthcare services. Along with low population density, this disparity is exacerbated by poverty, lack of providers, and sometimes low health literacy.

Women and Children's Health

Access to maternal and infant healthcare services are inconsistent across the US. Some regions of the nation have access to high-quality care with superb pregnancy outcomes. While other regions have inaccessible, inadequate or no obstetrical and pediatric care, and perinatal outcomes comparable to developing nations. Economically disadvantaged families in both rural and highly populated metropolitan areas are more likely to encounter barriers to accessing adequate maternal and infant healthcare. Barriers include great distances that one must travel to obtain services; particularly a concern for families in sparsely populated frontier areas. Low population density creates challenges for a community to recruit healthcare providers and sustain basic and specialty healthcare services. Essentially, access barriers (i.e. health disparity) impact health outcomes of rural populations, especially vulnerable pregnant women, infants and children.

Maternal and perinatal health varies among regions and populations attributable to social, genetic, economic, and environmental factors. Less than optimal pregnancy outcomes among rural populations often are associated with impaired access to and lack of obstetrical and pediatric providers coupled with closure of a significant number of small rural hospitals across the nation. In frontier areas (fewer than six persons per square mile), obtaining obstetrical care may involve a pregnant woman traveling more than 150 miles (one-way) to see an obstetrician or to deliver. Distance and the lack of providers may be a factor in a pregnant woman delaying obstetrical care until after the first trimester; and sometimes even waiting until the third trimester. This commuting distance exists for children with special needs (i.e., emotional, physical, behavioral) and not receiving appropriate or adequate services. Likewise, rural children may not be receiving appropriate preventative care or the recommended anticipatory guidance. The closure of rural hospitals and obstetrical services has an adverse impact on pregnancy outcomes. The evidence suggests when pregnant women must travel "out of town" for prenatal care, they have a higher proportion of complicated and premature births. Additionally, they remain in the hospital for a longer time after the delivery, compared to those having more accessible obstetric and pediatric providers. Essentially, the inequitable distribution of health professionals contributes to the poor health status of rural women and their children.

Accidents, Trauma, Occupation-related Injuries

Accidents and trauma are serious threats that can lead to death and long-term disabilities. Rural populations experience a higher injury rate associated with motor vehicles, lightning, agricultural equipment, animal, firearms, drowning and recreational vehicles (boats, snowmobiles, all-terrain vehicles). In its most recent report from June 2019 covering 2017, the National Highway Transportation Safety Board reported 45% of traffic fatalities occurred in rural areas. https://crashstats.nhtsa.dot.gov/#/PublicationList/56

Unfortunately, precise data is limited in respect to the incidence and prevalence of occupational and recreational related injuries in rural populations.

In recent years there has been a focus on the agriculture industry rates of morbidity and mortality. Agriculture has been noted to be one of the more dangerous industries. Other high-risk occupations that exist primarily in rural settings include mining, timber, fishing along with agriculture. Of these, agriculture had the greatest increase in mortality and morbidity rates. Surprisingly, the increase in agriculture rate occurred during a period when the actual number of individuals who were actively engaged declined. https://www.osha.gov/dsg/topics/agriculturaloperations/index.html

 

Did you know?

  • Unique health risks associated with the predominant rural occupations and environmental contextual factors; such as, farm machinery accidents, skin cancer from sun exposure, respiratory problems associated with exposure to chemicals and pesticides, mining related injuries, injuries associated with the timber and fishing industries.

Unlike other high-risk industries, agricultural work must be performed under the most adverse conditions such as inclement weather (snow, rain, mud, flooding), extreme temperatures along with long hours – all associated with uncertain productivity outcomes. Likewise, the agriculture work force is diverse in respect to age and work experience. For example, most farm and ranch enterprises are small family operated enterprises. Consequently, it is not unusual for family members, children and less experienced relatives to assist the owner with the seasonal work (i.e., planting, cultivating, harvesting, animal reproduction, etc.). Generally, they assist without regard to level of competency, safety training and sometimes even physical limitations or disabilities. Historically, migrant farmworkers have been the source of a low-cost and somewhat reliable labor force. Migrant farmworkers often comprise families (i.e. adult males and females of an extended family along with children of various ages) who work very long hours in crop production and food production industries (beef, pork, chicken, etc.).

Agriculture as an industry is reported to have the highest number of injuries and deaths among adult females and children. Fatality rates for young workers (ages 15-17) are higher in agriculture than every other industry combined. However, morbidity and mortality data are inconsistent and for these vulnerable workforce populations. Occupational related morbidity and mortality rates associated with the agriculture industry are more readily available from the US Department of Agriculture and OSHA. https://marshfieldresearch.org/nccrahs

 
Farm youth fatalities

Fatality Rates Agriculture vs All Other Industries, 2001-2016

Source: Fatal injury totals were generated by NIOSH researchers with restricted access to the Bureau of Labor Statistics (BLS) Census of Fatal Occupational Injuries (CFOI) microdata; additional information at www.bls.gov/iif/oshcfoi1.htm

Figure 5

Mortality and morbidity rates often are unreported for migrant workers and immigrants employed in agriculture, especially with the potential for being undocumented. Likewise, information is scant about the day-to-day "lived" experience of families in which the male head-of- household was involved in a serious injury or death. Since family operated agribusiness tend to be small, the owner is not required to carry Workmen's Compensation Insurance. These industry realities reinforce the need for education regarding occupational and recreational safety focusing on the prevention of injuries and death and the treatment of emergency events that prevail in a rural context. https://www.osha.gov/dsg/topics/agriculturaloperations/index.html

Associated with having less access rural residents tend to be sicker when seeking health care. The impoverished, of which there is a higher percentage in rural also have a higher incidence of chronic illnesses and health problems. The increase in chronic health problems in rural populations partly is attributable to a higher proportion of elderly and at-risk populations who reside in rural communities along with occupational and recreational accidents and injuries. While rural residents are reported to access healthcare less frequently compared to urban; when doing so, they tend to be sicker, more likely to be hospitalized, with more in hospital days. Subsequently, rural residents are reported to have higher rates of chronic disabilities and illnesses.

Accidents (unintentional injury), followed by suicide and homicide are leading causes of death nationally for teenagers between 15 years to 19 years of age. Each year at least 5000 young people are murdered and a higher number commit suicide, with more than twice as many dying from unintentional injury. Demographically, homicide is more likely to occur in the inner-city; and, suicide is reported to be more prevalent in suburban and rural settings. However, determining the cause, be it suicide or accidental can be difficult to determine. For instance, it can be difficult to make a clear determination if a death from a vehicle accident occurring on a lonely two-lane highway is accidental or an "actual or inadvertent" suicidal attempt. Or, it may be difficult to determine if a death from a drug overdose was accidental or intentional.

In the past two decades there's been a sharp upsurge in the national suicide rate, especially among rural male adolescents and young adult males. Death by suicide can be devastating in a small school and community where most residents are acquainted or even related (i.e., extended family). A variety of reasons are cited for the increase of attempted and successful self-inflicted deaths among rural males, such as uncertain economic trends, changing community demographics; tobacco, drugs and alcohol use coupled with lack of access to primary prevention and mental/behavioral health resources and providers.

Alcohol and Drug Use

Reports from the Substance Abuse and Mental Health Services Administration (SAMHSA). (2018). Key substance use and mental health indicators in the United States: Results from the 2018 national survey on drug use and health provide some insights into rural behavioral and mental health. https://store.samhsa.gov/product/Key-Substance-Use-and-Mental-Health-Indicators-in-the-United-States-Results-from-the-2018-National-Survey-on-Drug-Use-and-Health/PEP19-5068

Rural and Urban Substance Abuse Rates
(ages 12 and older, unless noted)
 Non-metroSmall metroLarge metro
Alcohol use by youths aged 12-2037.8%35.3%34.3%
Binge alcohol use by youths aged 12 to 17 (in the past month)5.5%4.9%4.7%
Cigarette smoking28.5%24.1%20.5%
Smokeless tobacco use8.5%5.0%3.0%
Marijuana11.2%13.2%15.0%
Illicit drug use14.2%17.3%19.4%
Misuse of Opioids4.0%4.4%4.5%
Cocaine1.1%1.8%2.1%
Crack0.2%0.3%0.4%
Methamphetamine0.7%0.6%0.4%
Source: Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2016 National Survey on Drug Use and Health: Detailed Tables.

When compared to urban adults, rural adults have higher rates of alcohol abuse, tobacco use, and methamphetamine use. Overall drug overdose death rates, which had been higher in rural areas, have shifted to being higher in urban areas since 2014. For drug overdose deaths involving natural and semisynthetic opioids, the rate is higher in rural areas.

The Rural Health Policy Reform Research Center reported that substance use disorder treatment admission rates in nonmetropolitan counties was highest for alcohol as the primary substance, followed by marijuana, stimulants, opiates, and cocaine. Prescription drug abuse and illicit use has grown across the urban-rural continuum. In rural areas, substance use disorder can be especially difficult to combat because of limited resources for prevention, treatment, and recovery. https://www.ruralhealthinfo.org/topics/substance-abuse

Factors contributing to substance abuse in rural areas include:

  • Low educational attainment
  • Poverty
  • Unemployment
  • High-risk behaviors
  • Isolation
  • Lack of primary prevention
  • Lack of specialized mental and behavioral health professionals and services
 

Did you know?

Health disparities exist in many rural communities including;

  • Higher infant-maternal morbidity/mortality rates
  • Higher rates of chronic illnesses, including hypertension, cardiovascular disease, certain types of cancer, diabetes, and obesity

To address the rural access disparity, health professionals providing care to rural clients, regardless of specialty, should also assess for depression and substance use and abuse. Rural healthcare providers of all specialties must assess, identify, and refer at risk individuals to appropriate resources within the community if available; and also be knowledgeable about relevant services and resources outside of the community. Referral information is essential especially when there are limited mental and behavioral health professionals to address this crisis in rural regions.

Health Professional Shortage Areas (HPSAs)

Nationally, healthcare delivery is changing to reduce cost and improve healthcare outcomes. Policymakers have implemented various to deliver accessible and equitable care especially in health professional shortage areas (HPSAs). It is not unusual for a county to have certain areas designated as an HPSA; however, most counties designated as such are located in rural areas across the 50 states. https://bhw.hrsa.gov/shortage-designation/hpsas

 
Health Professional Shortage Areas

Health Professional Shortage Areas (HPSA) - Primary Care

https://data.hrsa.gov/ExportedMaps/MapGallery/HPSAPC.pdf

Figure 6

The next section of highlights commonly encountered healthcare delivery issues that impose challenges for rural residents and providers in the context. Health professionals who practice in urban areas and provide outreach services to rural patients should also be aware of the issues associated with the availability, accessibility, affordability, appropriateness and acceptability of healthcare services in rural settings.

Availability of Services

Availability refers to the existence and the necessary personnel to provide a healthcare service. In rural areas, there are fewer physicians, nurses, and other types of healthcare providers and specialists. Sparse population limits the number and array of services in a region as the cost of offering services to a low number of people can be prohibitive. Thus, innovative approaches are needed to reach these underserved populations. Telehealth and telemedicine technology increasingly is used to reach underserved populations. For instance, specialist mental and behavioral health consultation along with health promotion education increasingly is delivered via telecommunication technology to address the rural access disparity.

Accessibility and Affordability Of Services

Accessibility refers to whether a person has logistical access to, as well as the ability, to purchase needed services. Closely associated with accessibility is the affordability of services. This means that services are priced within a range that consumers can afford. Accessibility and affordability to healthcare by rural families can be impaired by a variety of factors, including:

  • geographical distances that must be traveled to obtain services.
  • lack of public transportation.
  • lack of telecommunication technologies and/or cellular connection associated with geographical terrain or lack of infrastructure
  • insufficient numbers of providers to offer outreach services
  • Inequitable reimbursement policies by Medicare, Medicaid and other third-party payers.
  • unpredictable and inclement weather conditions that hinder commuting great distances
  • inability to obtain entitlements to obtain services
  • lack of resources to purchase health care insurance
  • low health literacy that impacts both accessing care and adhering to recommended treatment protocols

Consider the case of a farmer with a high income who resides in a county designated as HPSA. One day while working in the field, he suddenly collapses due to a myocardial event. Even though the family has the most comprehensive medical insurance, he is not be able to access the most basic emergency medical care as these services are located a great distance from the family home. When emergency care is not available, as often is the case in regions designated as an HPSA, residents are less likely to have essential emergency services when needed and accessible follow-up rehabilitation.

 

Did you know?

  • Health professionals must consider the belief systems and lifestyle of rural populations when planning, implementing and evaluating healthcare and nursing services.
  • Professional – community partnership models can be an effective way to provide a continuum of care to residents in environments with scarce healthcare resources.
  • There are variations in the health status of rural populations. Factors that impact health status include genetic, sociocultural, environmental, economic and political factors.

Access to funding sources to implement new programs is another challenge which often is hampered by the lack of grantsmanship skills among community leaders. "Grantsmanship skills" are critical to obtain the financial support for developing and sustaining health related resources. Successful grant writing requires practice, experience and collaborative efforts among agencies. It also is critical for the grant writer to have the dedicated time to produce and implement a fundable project.

Political structures in small towns also can hamper obtaining outside funding. For instance, community leaders may oppose outside "government interference" or the grant writer is unable to quantify immediate benefits from the proposed program. It is not unusual for rural residents to promote and value local efforts while opposing interventions supported by "federal and state bureaucrats". In other instances, community residents may see value in initial grant funding; however, concerns relate to the inability to sustain the initiative after grant funding subsides. These examples reinforce the challenges, the accessibility, and affordability to healthcare services.

Appropriateness and Acceptability of Services

Appropriateness and acceptability of services refers to whether a service is offered in a manner that is congruent with the preferred values of the target population. If the service is not congruent, the program probably will not be used by those consumers. Considering the wide diversity among rural populations, acceptability of services can be hampered in the following ways:

  • Adhering to traditions of individuals solving personal problems
  • Preferring culturally based self-care behaviors for a health problem (e.g., stoically suffering and pain because this behavior is associated with "machismo")
  • Believing physical suffering has a spiritual benefit. That is, one can redeem earthly wrongs (i.e., "my sins"); subsequently, rewarded with higher place in the next life
  • Using over-the-counter medication based on the recommendation of a highly regarded family healer or member (e.g., a relative with some background in nursing; or with familiarity of veterinary medications).
  • Believing a disorder should be treated by an indigenous healer (e.g., seeking skills of an indigenous healer, shaman, curandero, medicine man, voodoo priestess, herbalist, homeopath or chiropractor)
  • Believing illness is the physical manifestation of not being in harmony or balance with one's natural life forces.
  • Lacking accurate information about the cause and treatment of a medical condition
  • Equating obesity with attractiveness or family affluence.
  • Seeking professional care only in certain circumstances; for example: only in an emergency as opposed to obtaining and paying for health promotion or illness prevention interventions
  • Believing quality of life and death inherently means care should be provided by family members, friends and neighbors.
  • Receiving care in the small, local hospital (i.e., Critical Access Hospital [CAH]) with better access to extended family; as opposed to being hospitalized in a large urban healthcare center and receiving care from unknown specialists and nurses.
  • Assuring confidentiality and anonymity (HIPAA) in a community where most residents and health professionals are acquainted
  • An urban orientation of health professionals who serve rural populations.

Most health professionals are educated in an urban setting in which institutions of higher learning are located. Consequently, most student clinical experience also occurs in urban based healthcare facilities. In other words, most students entering the health professions are rarely if ever exposed to the rural context or the healthcare needs of populations therein. The urban frame of reference perpetuates cultural insensitivity about the rural lifestyle and the people who live there. Rural insensitivity coupled with the usual stresses experienced by a person seeking healthcare perpetuates mistrust of health professionals which can impact health outcomes. Lack of rural sensitivity also becomes evident when urban based providers rotate to provide outreach specialty care in distant communities. Rural residents report: "Every time I go to the clinic there is a different doctor . . . start over again… Getting to know each other and explaining my symptoms…". Patient satisfaction tends to be negatively impacted in these outreach arrangements. Consequently, a rural resident with the economic means seeks healthcare outside of the local community, rather than supporting local providers.

Cultural Sensitivity

Cultural sensitivity is evidenced by a provider being aware and respectful of an individual or population's lifestyle and beliefs; then, providing care that meshes with those preferences. Healthcare providers who are culturally connected and attuned to a patient's preferences are equipped to provide meaningful care and oftentimes with the better healthcare outcomes.

For instance, the Indian health service (IHS) provides healthcare to registered Native American tribes on reservations and urban based IHS facilities. Historically underfunded, IHS serves only registered tribal members. It is not unusual for a tribal IHS Council to contract with nearby medical centers and specialist to provide care to enroll tribal members. The IHS persistently experiences critical shortages of Native American nurses, physicians and other health types of professionals. Many health professionals who work in IHS are of nonnative origins who may not be not be culturally sensitive, which is a concern among Native Americans leaders.

A successful health promotion program that addressed the availability, affordability, accessibility and culturally appropriate event is a Health Fair held in conjunction with the annual County Fair. Historically the county fair is scheduled one week before school begins. Most residents from surrounding areas in the county attend the annual event. The Health Fair is sponsored by the County Public Health Department in partnership with other local healthcare providers and agencies. The Health Fair is well received by the community as the time to update immunizations (i.e., children and adults), and participate in hypertension, glaucoma, cholesterol and diabetic screenings. Health promotion and lifestyle behavior education information is provided focusing on stress management, smoking/tobacco cessation, safe sex, substance use/abuse, emergency use of naloxone, exercise/fitness, occupational health/safety, sleep hygiene, mammograms, and child-rearing among others.

Along with county fair marketing, the Health Fair is promoted by local service organizations, faith communities along with public service announcements in media (newspaper, radio, television, social media, etc.). The Health Fair is an ideal opportunity to address health promotion and primary prevention gaps in targeted populations. County residents look forward to the event and many individuals access "no cost services" provided by local health professionals who volunteer their time to participate in the event. Essentially, this partnership event is viewed favorably as accessible, available, affordable, appropriate and acceptable by community members.

An example lack of cultural sensitivity is healthcare providers in a large medical center who provided follow-up care to Native American children at risk for sudden infant death syndrome (SIDS). Some of the nurses who care for these families reported Native American mothers were "noncompliant" (i.e., "nonadherent") with prescribed treatment regimens for their infants; coupled with a pattern of persistent tardiness and missed clinic appointments. Conversely, the mothers described provider indifference and cultural intolerance toward Native Americans, which further contributed to their nonadherent behaviors. Intercultural conflicts in many instances can be reduced by professionals becoming more familiar with belief systems and lifestyles of a particular Native American tribe, in this case Sioux and Cheyenne tribes.

Newborns are initially screened by pediatric nurse practitioners to assess for SIDS risk. The assessment takes place in a clinic located 100 miles from the reservation (where Native American families reside). Subsequently, infants identified as "high risk" are discharged with an apnea monitor. Mothers are instructed to: "Always place the monitor on the child when sleeping". Nurses and social workers reinforce to the mother the importance monitor placement on the sleeping child. A high proportion of the Native American mothers are young (adolescents, young adult). However, according to Native American health aides (from the reservation) who make home visits to the family they found apnea monitor adherence rate to be very low. Upon questioning by the nurses at scheduled follow-up appointments the mothers stated; "I usually connect my baby to the machine when he/she sleeps". Subsequently, nurses and social workers accused mothers of not being truthful ("lying") when asked about adherence of infant monitor placement during sleep.

This discrepancy is associated with nurses not being aware of physical and social determinants that may contribute to mothers' "noncompliant behaviors". For instance, it is not unusual among some Native American families to have their children raised by extended family members (i.e., aunts, uncles, grandparents). For example, the mother's sisters and mother (i.e. "aunts and grandmother to the child") assume active child-rearing responsibilities for female children. Uncles and grandfathers sometimes assume a major child-rearing role for male children and adolescents. That too is the case for infants identified at-risk for SIDS. Yet, in the discharge planning, only the mother was instructed; nurses did not involve extended family members or elders in the education and discharge planning. Likewise, some Native American elders are not proficient in the English language; most have limited health literacy proficiency. To complicate matters, urban-based health professionals are unaware that some homes on the reservation do not have electrical power or indoor plumbing. Had such social determinants and lifestyle realities been considered by the health professionals, the discharge planning could have been adapted to fit the families contextual and lifestyle realities.

Rural Focused Legislation

Over the decades, legislation has been implemented by local, federal and state governments with the intent of improving rural access to health care. While well intended, federal legislation often negatively impacts rural populations. Partly this is attributable to elected officials' lack of awareness of rural contextual features that can impact accessibility, availability and acceptability of services. It is not efficient, prudent or effective to simply adopt a mandated highly successful program that occurs in a more populated city and transplant that model into a rural setting. Most mandated programs often create "more red tape" and impose different barriers and higher costs which further hinders access to services by rural populations. Federally legislated programs specifically targeting underserved populations include, the Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC), Critical Access Hospitals (CAH) and Indian Health Service (IHS). These programs will be briefly examined in the next section of this program.

Rural Health Clinics (RHC)

The RHC is a clinic located in a "rural area designated as a shortage area". An RHC is not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases; and must meet all the requirements of 42 CFR 405 and 491. The intent of the RHC program was to increase access to primary care services for patients in rural communities. RHCs can be public, nonprofit, or for-profit healthcare facilities. To receive certification, an RHC must be located in rural, underserved areas. RHCs are required to use a team approach of physicians working with non-physician providers such as nurse practitioners (NP), physician assistants (PA), and certified nurse midwives (CNM) to provide services. The RHC must be staffed at least 50% of the time with a NP, PA, or CNM. RHCs are required to provide outpatient primary care services and basic laboratory services. One advantage of RHC status is enhanced reimbursement rates for providing Medicare and Medicaid services. https://www.ruralhealthinfo.org/topics/rural-health-clinics

Federally Qualified Health Centers (FQHCs)

Federally Qualified Health Centers (FQHC) are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas in both rural and urban settings. FQHCs must meet a stringent set of requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients. Federally Qualified Health Centers may be Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Health Centers for Residents of Public Housing. The defining legislation for Federally Qualified Health Centers (under the Consolidated Health Center Program) is Section 1905(l)(2)(B) of the Social Security Act. https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc/index.html

Critical Access Hospitals (CAH)

Critical Access Hospital is a designation for eligible rural hospitals by the Centers for Medicare and Medicaid Services (CMS). Congress created the Critical Access Hospital designation through the Balanced Budget Act of 1997 (Public Law 105-33) in response to a string of rural hospital closures during the 1980s and early 1990s. Since its creation, Congress has amended the CAH designation and related program requirements several times since then through additional legislation. The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. To accomplish this goal, CAHs receive certain benefits, such as cost-based reimbursement for Medicare services. Eligible hospitals must meet the following conditions to obtain CAH designation:

  • Have 25 or fewer acute care inpatient beds
  • Be located more than 35 miles from another hospital
  • Maintain an annual average length of stay of 96 hours or less for acute care patients
  • Provide 24/7 emergency care services

https://www.ruralhealthinfo.org/topics/critical-access-hospitals

Indian Health Services (IHS)

"The Indian Health Service (IHS), is an agency within the Department of Health and Human Services is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally-recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders. The IHS is the principal federal health care provider and health advocate for Indian people, and its goal is to raise their health status to the highest possible level. The IHS provides a comprehensive health service delivery system for approximately 2.6 million American Indians and Alaska Natives who belong to 573 federally recognized tribes in 37 states." The IHS has 12 regional administration units (i.e., area offices), and operates hospitals, community health centers, school health centers, and clinics across the 50 states. The IHS provides a spectrum of preventive, curative, rehabilitative, and environmental services. In brief, the federal government is concerned about the need for vital services in underserved rural areas and has implemented legislation to address these needs. In addition to being available, accessible and affordable programs that are designed as culturally appropriate and acceptable by enrolled tribal members. https://www.ihs.gov/aboutihs/overview/

Rural Lifestyle

What is it like to live and work in a small rural town? What do we know about rural populations and their healthcare needs and care seeking behaviors? Even though each community is unique in many ways the experience of living and working in a small town is similar across the 50 states. In fact, these rural features may be internationally similar. While each community is unique, and the human experience varies widely, rural lifestyle often is exemplified as:

  • Greater spatial distances between people and services, and economic orientation relating to the land in nature (i.e., agriculture, mining, timber, lumbering, fishing – all listed as high-risk occupations by OSHA)
  • Occupations and recreational activities tend to be cyclical and seasonal in nature.
  • Social interactions that facilitate informal common face-to-face negotiations because most, if not all, residents are either related and/or acquainted.
  • A small town is the center of trade for a region and its churches and schools usually are the centers for socialization.

In the following discussion, common themes and belief systems among rural populations are examined in the next few paragraphs. It is important to emphasize, however, while the following discussion addresses general themes, the comments do not address the unique beliefs and behaviors of the numerous subgroups and vulnerable populations who reside in rural areas across the 50 states. In other words, rural is diverse and each community is unique!

Rural Belief System (Themes)

Common themes that one often hears in conversations with rural residents include the fatalistic subjugation to nature (i.e., rain or frost effects on crop production; fire impact on the timber industry; "hard winter" effect on the livestock industry; hurricane effects on the fishing industry, etc.) with an orientation to concrete places and things. Based on recent political polls, compared to urban, rural residents are reported to be more conservative with a notable religious preference ("churchgoing"). These preferences among others also influence one's lifestyle, health beliefs and care seeking preferences (Bushy, 2006).

Social Dynamics

In day-to-day activities rural residents report a preference for interacting with people they know, rather than someone known less well or a stranger. Informal social preferences include extended family, friends, local acquaintances, and neighbors. Informal relationships tend to be more readily accessible as well as advantageous and often are a source of support. For example, aiding an individual or family in an emergency, e.g. helping the farmer or assisting in a family owned grocery store; or, providing childcare during an illness or birth of the new child. (Vermont Ethics Network, 2020, https://vtethicsnetwork.org/medical-ethics/rural-health-care-ethics)

Familiarity associated with informal social structures contribute to some rather unusual concerns. For instance, where most residents are acquainted there are challenges in maintaining confidentiality and anonymity associated with more sensitive personal issue or a health problem (e.g., stigma associated mental illness, sexual transmitted disease, interpersonal violence, substance abuse). Breaks in confidentiality can have serious consequences when seeking healthcare or social service services such conditions. (Issues related to confidentiality and anonymity will be discussed in greater length in a subsequent section of this continuing education program) (Bushy, 2006)

Public knowledge about one's personal problems in a small community can be a devastating experience for the individual, family members and sometimes even friends. Consequently, it is not unusual for a rural patient to imply not trusting anyone to discuss a personal problem. Social structures can impose an access barrier for someone needing professional help for sensitive problems having moral overtones (e.g., drug or alcohol dependency, unplanned pregnancy, sexuality related issues, interpersonal violence, behavioral and psychiatric problems).

Social Support Preferences

Three levels of social support are identified in the literature Swayne, 2020). The first level includes services volunteered by family and friends. Generally, there is no remuneration for such informal helping activities. Often however, there is a code of reciprocity among the volunteers (i.e. neighbor, extended relative, friend, etc.).

The second level includes services are provided by a group or organization, (e.g., civic/service organizations, church circles, fraternity organizations, Chamber of Commerce, 4-H clubs, recreational/hobby groups). The membership assists individuals and families in need (e.g., volunteering time, food, nonmonetary (in-kind) donations, financial contributions, etc.). In recent years, the social media provides support albeit anonymous (sometimes questionable) to individuals with electronic communication capability (e.g., GoFundMe, Facebook, email, Twitter, etc.). The first two levels of social support provide a mutually understood, oftentimes unspoken, "insurance policy" should a catastrophic event present for members in the network. (Bushy, 2006) https://news.psu.edu/story/577765/2019/06/13/research/despite-dire-predictions-levels-social-support-remain-steady-us

The third level of support includes formal (public) services sponsored by governmental agencies and private industry, e.g. public health agency, community nursing service, mental health center, school counseling services, etc. Generally, remuneration is required for provided services; albeit, on a fee based on income (i.e., sliding scale). Comparing utilization patterns of the three levels of support, urban residents tend to prefer the third level.

Historically to cope with hardships and geographical isolation, rural families were forced to rely on informal social support systems. Informal help seeking behavior reinforces the perceived notion of "self-reliance". Recent demographic shifts in many rural communities across the US have disrupted historically established informal helping systems. The phenomenon associated with working age adults leaving small communities, increasingly has forced rural residents to rely on formal or publicly supported services rather than on neighbors and extended family. In medically and more remote rural communities increasingly health related services are provided by urban-based health professionals on a rotating basis. Disenchantment and low satisfaction are not uncommon with urban-based providers who do not understand the rural context or the beliefs and practices of the people who live there (Bushy, 2006)

Self-Reliance

Self-reliance refers to lifestyle behaviors and self-care practices that is a characteristic often attributed to rural residents. Whether or not this attribute is evidence-based remains debatable. Historically, however, self-care helped people survive in austere, isolated and rugged environments. Self-reliance is reflected in the following statement: "We take care of our own."; inferring a preference for receiving care and interacting with those whom one is well acquainted. This attribute has implications for health promotion and illness prevention interventions. Friends, neighbors and family have a role in promoting healthy lifestyle behaviors, such as using automobile seatbelts or a bicycle/motorcycle helmet, assuring children's' immunizations are current, using tobacco products, street drugs and over-the-counter medications, as well as participating in occupational and integrating recreational education safety behaviors (Bushy, 2006).

In other instances, informal relationships enable unhealthy interactions and care seeking behaviors. A close-knit extended family can be supportive to one of its members in time of need. In other cases, family pride can hinder or deter that individual from acknowledging the problem or seeking appropriate care to address the situation. For instance, an emotional or behavioral problem may be viewed by family and friends as, "odd", or "family skeleton ". Secrecy may be reinforced by the code of silence; that is to say: "What t happens in the family – stays in the family". This adage is often accepted by residents (i.e., family, community members) who lived and worked in the same community for generations.

To preserve family integrity in the community (i.e. "save face") it is important that not everybody in town hears about the problem, e.g., substance abuse, domestic or interpersonal violence, incest, behavioral problems or psychiatric disorders. Informal relationships contribute to inaccurate or ambiguous reporting (i.e. "shading the truth"); or, providing incomplete information to a healthcare provider on sensitive health conditions or family dynamics. Adhering to family and community norms can lead to excessive stress for individuals, especially when struggling to develop a sense of identity (i.e., adolescents, individual with low self-esteem, etc.).

Work Ethic

Rural economic structures and a community's predominant industry can impact a population's health status and care seeking behaviors. For instance, small family owned business ventures characterize small rural communities. Economic enterprises such as farming, ranching, grocery store or service station generally do not provide robust employee benefits compared to large industries (e.g. health insurance, retirement plan). Consequently, some rural residents define health as; "The ability to work and do what needs to be done". This comment values the strong work ethic; and, inferring that illness as, "Not being able to do one's usual work"(Bushy, 2006).

Health Care Utilization

Social and physical determinants influence an individual's and family's choice of leisure activities, perspectives about mental/behavioral health, health promoting activities and health care seeking behaviors. For instance, for a family living in a sparsely populated area, it is not unusual to coordinate a physician appointment in a larger city, with purchasing groceries and farm machinery parts; and perhaps, visiting a relative while in town. Or, updating required immunizations for school-age children during the annual county fair. Or, eagerly anticipating services provided by the parish nurse, but being hesitant about discussing personal problems with a social worker who lives and works in the same community. In another scenario, individual may not feel "connected" to an outreach provider (i.e., social worker) who is one of several rotating outreach providers from the large medical center located 100 miles; and, travel biweekly for appointments at the county mental health clinic. (Bushy, 2006).

Professional Practice

Debate persists whether there is anything unique about rural professional practice in comparison to practice in another setting. Documented evidence on rural practice is sparse and inconsistent in the health professional literature. Within the last two decades, community and public health textbooks generally include a chapter on rural issues. Considering the wide variations among rural communities, what is the best approach to preparing health professionals to remain in practice in these less populated environments? What knowledge and skills do health professionals need to survive and provide care to rural and underserved communities? Finally, what entices and individual to practice in a rural context? The next section highlights features of rural practices, and nurses in particular.

Learn About A Community

Social and physical determinants refers to environments in which people are born, live, learn, work, play, worship, and age; and, can impact a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as "place." Attributes of "place," impact people where they live including patterns of social engagement, sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins. In other words, social determinants to consider in a rural community would include socio-economic characteristics, the environment, poverty level and demographics factors. Understanding the relationship between how population groups experience "place" and the impact of "place" on health is fundamental to the social determinants of health—including both social and physical determinants. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

Since most students in the health professionals are not exposed to the rural context and rural health problems, faculty should create opportunities to address this educational deficiency. For example, learning about predominant morbidity and mortality rates that impact the people in a market area (i.e., community). The USDA description of predominate economic infrastructures is one approach to learn about more common health conditions associated with socioeconomic factors and lifestyle preferences. For instance, in a community in which agriculture and ranching predominate, one could expect to see a higher incidence of machinery and animal related injuries and trauma, heart disease, skin cancer and respiratory problems. When caring for Native Americans, using IHS morbidity and mortality data, one would expect to find higher rates of diabetes, substance use/abuse, and cirrhosis of the liver, automobile accidents, hypothermia, and suicide. In communities with high numbers of African American's one could expect to see higher rates of about hypertension and obesity. In a community with a population of migrant farmworkers, one might expect to encounter a higher fertility rate as well as health risks associated with lack of access to safe water and sanitation and exposure to agricultural chemicals (i.e. pesticides, herbicides, fertilizers). Among Alaskan natives, it is important to consider exposure to risks associated with hypothermia and exposure to petroleum byproducts. The Centers for Disease Control (CDC), the Occupational Safety and Health Administration (OSHA), USDA and IHS are useful resources for health statistics, along with physical and social determinants that pose risks for select populations' health (Bushy, 2006).

Confidentiality and Anonymity

Familiarity has advantages and disadvantages; and can poise threats to anonymity and maintaining confidentiality in rural practice. On one hand, some professionals report they enjoy being personally acquainted with many localities. In other words, personally knowing clients, who may also be a neighbor, friend and relative (friend of children, spouse, siblings, parent). On the other hand, some professionals are very uncomfortable with the diffuse personal-professional boundaries. As with all facets of professional life familiarity, too, has both advantages and disadvantages. A rural-based physical therapist describes the experience in these terms:

"Personally, knowing the client and his or her family lifestyle helps me to provide total and comprehensive care. After I provide therapy, I'm able to follow the person's progress either from direct reports by clients or word-of-mouth reports from the family, friends or neighbors." (Donna B., personal communication, 2017.)

Nurses and physicians are highly esteemed and considered an important healthcare resource in rural underserved communities. Public recognition can pose threats to anonymity and confidentiality which is a profound practice consideration in a highly populated area versus a small close-knit community. A nurse who worked in both rural and urban settings put it in these words:

"In an urban setting, when you leave work and drive your car out of the parking lot you are just one more person in a large city. In a rural area when you move your car out of the parking lot, you are the same person you were when you were in the parking lot. Everywhere you go, you are recognized as the doctor, or nurse, or social worker. This affects how you conduct yourself in public as well." (Carol F., Personal Communication, 2016).

A social worker expands with his perspective of living and working in a small rural community:

"Sometimes knowing the patient allows me to make assumptions about the person without valid data… Missing something important… Emotions can get in the way… Sometimes, I have trouble being objective in providing care or therapy for a client that I know very well, or that I know one of my family members knows quite well." (Robert S., Personal Communication, 2017).

Closely related to the lack of anonymity among residents of a small town, are threats to maintaining confidentiality. For example, sometimes community health and social service agencies are situated in a public facility such as the city/county government building or a federally qualified health center. In these facilities, space is often limited; waiting rooms are small and confined. Sometimes, several agencies share a common hallway or waiting area. Consequently, it is not unusual for local residents to cross paths when seeking services from one of the agencies.

Implementing Health Insurance Portability and Accountability Act (HIPAA) mandates also can be a challenge in a small community where most people are acquainted. For example, information provided in the local media or public service announcements (PSAs) informs residents about the time for family planning clinics, HIV screenings, women, infant and children nutrition (WIC) program or immunization clinics. Sometimes the announcements are posted in a public place, such as the bulletin board located at a grocery store, service station, grain elevator, or in a congregation's Sunday bulletin. Such marketing and promotional activities can present challenges to maintaining confidentiality for a client who uses those services. Chance encounters in waiting room among patients, either advertently or inadvertently, facilitates the exchange of local information (i.e., "the grapevine").

Another potential threat to maintaining confidentiality is associated with local residents being recognized by the vehicle they drive. Therefore, when a person's car is parked in front of the building for a health-related service, locals come to assume someone in the family is seeking those services (e.g., mental/behavioral health, WIC, public health services, etc.). Be it real or perceived, threats to confidentiality associated with chance encounters may deter seeking treatment and the person feeling stigmatized as it becomes public knowledge (Vermont Ethics Network, 2020, https://vtethicsnetwork.org/medical-ethics/rural-health-care-ethics)

Threats to anonymity and confidentiality encourages some residents to seek care outside of the local community or avoid seeking care at all. This reality should be considered by health professionals when planning, delivering and evaluating services. For example, deciding the best location for a practice, and marketing and coordinating when service will be offered to address the target population's needs and preferences. For instance, offering extended practice hours in an FQHC or RHC for seasonal farmworkers or single parents. Examples of effective strategies are to coordinate parking with another service or business, arrange for electronic appointment scheduling, or seeing patients on a walk-in basis for highly sensitive situations such as sexual health, HIV screening, mental/behavioral health or family-planning services.

Gender Role Expectations

Anecdotally, some rural residents have a preference for adherence to more traditional gender role behaviors. In other words, advocating "men's work" and "women's work". In respect to women's work, historically their household and family-related activities were viewed as "less important" than men's work which focused on employment "to financially provide for the family". Females generally have not been compensated for "running the household and caring for the family's well-being." Most adult females work outside of the home these days, yet for the most part, are expected to carry out traditional role behaviors also.

Nursing, a predominantly female profession, often is viewed as "women's work" and physicians functioning in a "male role" Female health professionals are seen as "a nurse" while males in the health profession are deemed to be "a doctor", regardless of educational and licensure background. Biases and traditional gender expectations could impact recruitment and retention of health professionals in rural environments. In a rural community without home health services, physicians referred patients to a local "unemployed" nurse. Even though this person was heavily involved in her family business, she was expected to volunteer her nursing skills by residents and physicians alike. It is not unusual for residents in a rural community to consult a local nurse about a health problem before making a physician's appointment; or, expect that a nurse will voluntarily respond to local traffic accidents.

Isolation

Isolation (i.e., geographic, social, professional) can permeate the day-to-day practice of healthcare providers in a small and sometimes remote community (Franklin, Henning-Smith, 2020). Each person perceives and experiences isolation in a unique manner. While individuals perceive isolation as "loneliness, without support," others understand it to be "solitude, time to reflect and create". Geographical distance and isolation also must be taken into consideration when caring for patients. Some patients/clients, as well as other health professionals, may be located a great distance from a physician's office, public health clinic, hospital or mental health center. Subsequently, contextual features must be taken into consideration when scheduling appointments, writing prescriptions, and coordinating follow up care such as home health, hospice or extended rehabilitation services. (Vermont Ethics Network, 2020, https://vtethicsnetwork.org/medical-ethics/rural-health-care-ethics)

Professional and geographic isolation can be perceived as a positive or negative experience or combination thereof. For rural-based nurses, practicing without immediate access to a colleague, allows (i.e., requires) a certain level of self-confidence for professional independence, autonomy, and creativity. Such professional abilities may not be as essential for those who practice in a larger urban-based health care facility. For providers who lack confidence in their professional abilities and without a broad clinical knowledge base, rural practice expectations could be overwhelming. Professionals who are considering rural practice must be comfortable with their abilities, skills and be knowledgeable about local resources in order to make sound clinical decisions.

It is not unusual for rural professionals to not have "immediate accessibility" to a professional peer network that can provide support and consultation. This reality require that the professional have well-honed generalist skills to assess, diagnose and prioritize care for patients across the life span, having a wide range of health problems and diagnoses.

Enabling Technologies

Telecommunication has been instrumental addressing geographical and professional isolation health care access disparities. Increasingly, telecommunication, telemedicine, telehealth, electronic communication and social media are used for expert consultation and professional support in more remote and underserved communities with limited resources. Consultation provided by specialists located in an urban-based tertiary medical center provides instantaneous expertise for patients and their care providers. https://www.ruralhealthinfo.org/toolkits/telehealth/2/care-delivery/specialty-care

Satellite telecommunications connects an outreach clinic with colleagues at another state to discuss a complex emergency trauma, obstetrics, psychiatric, cardiac or renal conditions. Remote tele-monitoring allows synchronous and intermittent coronary, diabetic and postoperative monitoring of a patient who resides some distance from a cardiologist and critical care monitoring unit. Technology is also used to diagnose, provide follow up care, and for group support to individuals diagnosed with behavioral or mental health conditions; and, eliminates or reduces traveling for ongoing care. Telecommunication is instrumental for education to at risk populations on health promotion/lifestyle modifications and the prevention of chronic illnesses and behavioral/mental health conditions.

However, some rural communities do not have adequate broadband capabilities for telehealth and telemedicine Internet connections. Likewise, terrain features can limit cellular telephone connections (i.e., mountains, forests, "dead space"). It is important for elected officials and healthcare providers to understand the benefits and limitations of technologies to address the rural health care access disparities. Likewise, as new technologies become available that enable health services to be delivered virtually, i.e. independent of time or location, it is important to evaluate them for the potential of a positive impact on quality of care and outcomes. https://www.ruralhealthinfo.org/toolkits/telehealth/2/care-delivery/specialty-care

Recruitment and Retention of Health Professionals

Historically, rural health care facilities have had to address challenges in the recruitment and retention of various types of health professionals especially nurses, physicians, dentists and behavioral/mental health providers. Associated with geographic, social and professional isolation is the ever-present scarcity of human and financial resources that are readily available for rural practitioners. Resources, (or, the lack thereof) impacts the number of personnel positions, salary schedules, and the array of services that can be provided by a health-related organization (Franklin & Henning-Smith, 2020)

In small rural hospitals and health care agencies employee positions frequently are designated as "part-time" associated with insufficient financial resources to support a full-time equivalency (FTE) position, such as hiring a full-time social worker in the community mental health center; or, a full-time public health nurse for the county health department; or, a full-time dietitian for a long-term care facility. Additionally, there could be an insufficient number of patients to warrant financially supporting a full-time position. In other words, the area lacks the "critical mass" to financially support a professional. This rural budgeting approach is congruent with national trends to hire "temporaries" into unfilled FTE positions; or, implementing "flex scheduling"; or intermittent use of "travel nurses" and "locum tenens" to temporarily augment unfilled employee positions. Flex scheduling, for instance, allows for two or more individuals to fill one full-time equivalent (FTE) position.

Persistent reasons for unfilled FTE positions in rural healthcare facilities include qualified personnel are unavailable to fill personnel vacancies. Some attribute challenges of recruiting and retaining health professionals in rural areas to less competitive salaries and employee benefit compared to those offered in a large urban-based healthcare system. While the rural salaries and benefits in some cases may be less competitive, the cost of living generally is comparatively lower than in an urban setting. Another factor may relate to the urban orientation of health professional education and the lack of exposure to the rural context.

Nurses, physicians and other types of health professionals usually are well known by small town residents (i.e. also patients) (i.e., lack of an anonymity; threat to confidentiality) and for this reason specialist care is sought outside of the local community. This rural care seeking behavior further reduces the critical mass to viably support local health care services and providers. Another somewhat unique feature of practice in a small community are chance encounters with patients who provide updates on their current condition; or, may even ask for professional advice in the grocery store, gas station, youth activity, or church function. While some providers are quite uncomfortable with this informal social dynamic, others report they enjoy public recognition and informal client interactions (Franklin & Henning-Smith, 2020).

Rural communities are using creative approaches to address personnel shortages. Sometimes, two or more counties partner to hire essential personnel to provide services to residents. With such arrangements, a social worker, physical therapist, dietitian, public health nurse or parish nurse plans, coordinates and delivers services to residents in those facilities or market area. This may not be an ideal arrangement in regions where distances are great between the communities. Sometimes commuting distances between facilities impose excessive travel burdens on the person who is hired to fill the position such as for a multi-county public health district or community mental health center. Partnership arrangements usually work best in a more localized geographical region. Additionally, challenges in meeting the healthcare needs of the clients are reported by professional involved in partnerships that span a large geographical region. Terrain features can pose even greater challenges than distances, for instance traversing mountains and forests can contribute to hazardous commuting conditions. Terrain can also impact availability of cellular telephonic services and electronic communication (Franklin & Henning-Smith, 2020).

Generalist Skills and Practice Autonomy

Health professionals in rural practice settings usually are expected to fulfill various roles and functions. With the lack of specialty services obstetrics, pediatrics, cardiology, neurology, orthopedics and psychiatry there is an expectation of rural health professionals to function as "expert generalists". Some providers embrace this expectation and view it as both interesting albeit somewhat challenging to care for patients across the lifespan having various health related conditions and diagnoses. Other health professionals report they are very uncomfortable with this level of autonomy, the expanded role expectations and need for a wide range of skills. Since there may be a shortage of providers, for nurses in particular, it may be difficult to take time off to attend conferences or courses to enhance one's skill and knowledge level. Lack of institutional financial resources may prohibit securing intermittent backup relief ("coverage") to "take time off". Lack of readily accessible "backup" personnel increases demands placed on coworkers. One often heard complaint offered by rural health care providers is: "I am always on call… never off duty…24/7/365 days every year" (Bushy, 2006).

Legal and Ethical Considerations

Regardless of the setting, be it rural or urban, practice situations can arise that have legal and ethical dimensions. In rural practice, situations often are associated with the demand or expectation to function in a role in which the professional lacks the essential knowledge or skill. Consequently, health professionals who lack the confidence to make independent decisions or the confidence to make informed referrals would not fare well in a context with its few resources and limited access to colleagues. Individuals with these traits probably are better suited to function in a larger healthcare institution with readily accessible resources and peers to consult with. The need to prioritize allocation of scarce resources can be another source of ethical and legal conflicts for rural providers. The expanded practice rule might also lead to legal concerns that someone who is considering rural practice should further explore with the appropriate regulatory agency. More specifically, information must be sought regarding the state's licensure and credentialing requirements. For these reasons it is always prudent to establish rapport with other healthcare providers within the immediate community as well as in nearby communities. These connections are critical for a rural practitioner in order to have a consultation and referral network should emergency situations arise. https://vtethicsnetwork.org/medical-ethics/rural-health-care-ethics

In respect to professional standards of practice, established by professional organizations and state regulatory boards of nursing, are consistent for rural and urban alike. Providing safe, quality care is mandated in all client/professional relationships. In rural area achieving this outcome may require creativity to coordinate care in light of fewer resources and great distances that exist between services and clients.

Opportunities for Creative Practice

To be effective in the rural context, health professionals must be creative in coordinating and accessing resources. With respect to isolation, be it geographic or professional, most individuals have cell phones allowing them to readily connect with another provider or resource. Communications technology (when available) allows a rural provider to contact a colleague, specialist, emergency services or perhaps the county sheriff. Or in the case of a home health nurse, to contact "volunteers", or a parish nurse to coordinate services for a patient. Or, offering web-based emergency medical training (EMT) to interested individuals in medically underserved communities so they can respond to accidents and stabilize a victim for transfer to a hospital's emergency department.

Another example of creativity is a mental health professional in the activist role. He presented local mental and behavioral health needs to county commissioners who oversee the budget for the local health public health district. His goal was to promote awareness (using morbidity and mortality data) of the drug use and comorbid mental health conditions among adolescents, in order to obtain financial resources for crisis intervention services in the for the community.

In another community, volunteers who are veterans are recruited to transport veterans to the distant Veterans Administration Medical Center for appointments. Volunteers participate in an orientation program to become more knowledgeable about transportation safety as well as intervening in crisis situation. In other words, enhancing an individual resident's knowledge about particular issues has a multiplier effect in underserved rural regions. In other words, informing health professionals about formal and informal services to create a more robust resource environment in underserved contexts. Effective and ongoing communication among health professionals, volunteers and the community at large is critical for planning and implementing partnerships to better meet the health care needs.

Various strategies have been implemented to develop and enhance individuals and family self-reliance skills. Schools and churches often are socialization centers in small towns and rural communities. In turn, these facilities may be an ideal setting to offer health promotion and illness prevention education programs across the lifespan. Examples of educational programs in a rural setting could focus on occupational safety in the agriculture industry (or, other high-risk occupation), cardiopulmonary recession resuscitation (CPR), recommended immunization schedules for children and older adults, or health promoting lifestyle behaviors. Topics on stress management, nutrition education and fitness programs are welcomed by most adults.

The marketing industry is well aware that women usually make decisions regarding the family's health and healthcare seeking behaviors. While adult males may not overtly appear to be interested in health and health promotion topics, most women are eager for information for maintaining their family's health. Additionally, women often ask questions about men's health during their appointments with a health professional; then, telling a male partner the information. For these reasons, local women's organizations can be an effective setting to present health related programs on mental/behavioral health issues, preventive health recommendations across the lifespan, and internet safety for children.

Hobbyist and social groups can offer accident prevention education relative to recreational activities (hunting, boating, fishing, etc.), weapon safety, vehicles (trucks, automobiles, all-terrain vehicles, snowmobiles, farm equipment, boats, etc.) and emergency care accidents. People generally welcome first-aid information such as CPR and first responder interventions in drug over doses and mental health topics such as depression, substance use, and healthy coping skills associated with anger management. Individuals involved in agribusiness are eager to learn current information on safe storage, use and emergency response to toxic chemicals including herbicides, pesticides and fertilizers.

Other creative approaches are used to meet the healthcare needs of rural residents. For instance, a large health care system offering outreach/on-site immunization clinics and mammograms to rural communities in their catchment area. A local hospital offering a health fair that includes screening for diabetes, hypertension, cardiovascular risks and mental health assessment (e.g. depression, substance use/abuse). A healthcare provider that includes screening clinics could be scheduled to coordinate with a major communitywide event such as a church bazaar, county fair, stockholder/business dinner, basketball tournament or perhaps a rodeo. These creative strategies could be a cost-effective strategy to meet the needs of a targeted population while offering services that are available, accessible and (usually) appropriate and acceptable by the community. For those strategies to come to fruition, partnering activities are critical between healthcare providers and community leaders.

Partnerships

Case management is a partnership to coordinate a tailored continuum of care for the client. Case management often includes the client's family, friends and sometimes volunteers in planning and delivering the care. Case-managed care is especially effective in rural areas having fewer "formal" resources; and, blending formal with informal resources. Since the client is (i.e., should be) involved in the planning, ideally that care will be acceptable, appropriate and better equipped to navigate the healthcare system. The following case management exemplar highlights the manner in which formal and informal services are blended by a case manager to coordinate a preferred quality of life in a relatively safe environment.

 

Beth: Rural Case Management Exemplar

Beth, a 76-year-old widow was diagnosed with progressive Parkinson's disease. She has lived with this condition for at least a decade experiencing increasing physical rigidity and ataxia. She lives alone in a tiny three-room cottage along with her dog and three cats. The home is located at the edge of a very small town, having a population of fewer than 500 residents. Her homebound 82-year-old sister, Mary, continues to live lives nearby (i.e. approximately 5 miles away) on the family farm that was homesteaded by her great, great grandfather. Despite declining physical abilities, Beth adamantly declares she will not relinquish her privacy, independence and "eccentric lifestyle".

In the past 12 months Beth had two major hospitalizations. The first hospitalization was for a urinary tract infection, worsened by dehydration associated with the summer heat (her home has no air conditioning). The second hospitalization occurred after she was found by a neighbor lying unconscious in her yard under the clothesline. Upon discharge for the first hospitalization, a home health nurse was assigned care for Beth. Sue, RN is employed by a health agency located in the city located 70 miles away. Initially, Sue collaborated with the hospital's discharge planner to coordinate formal and informal resources for Beth's plan of care. The goal was for Beth to remain living in her home while ensuring an optimal level of safety, nutrition and hydration. With assistance she probably could continue most activities of daily living. Subsequently, a home health aide assisted her with personal care (e.g., bathing, grocery shopping) four times each week. Beth had the ability to communicate by telephone and email with extended family and neighbors.

Formal services included in Beth's care plan included, "Meals on Wheels", assistance with personal care with the home health aide and weekly welfare checks by local law enforcement personnel. Meals-on-Wheels meal preparation is coordinated by the senior center located in the town 20 miles away; delivering hot meal to enrollees five days each week. Extra meals for the weekend, easily heated and served by Beth, are delivered on Friday. The person who delivers Meals on Wheels has been educated to notice unusual behaviors or symptoms that warrant medical assistance among recipients. In such situations, the driver immediately calls emergency medical services located within the all-volunteer fire department. Subsequently, emergency services are dispatched to the home and transport the patient to the nearest critical access hospital (CAH, located 20 miles away).

Lack of access to emergency services is a serious problem in many rural communities. For example, when Beth lost consciousness and fell in her yard, the neighbor waited three hours for the ambulance. Fortunately, Beth regained consciousness and did not seem to have any serious medical consequences. Since that emergent situation Beth is wearing a medical alert bracelet that remotely connects to the emergency department at the CAH. The bracelet allows Beth to push a call button if she needs assistance or transmits an alert to the CAH. This allows emergency department personnel to monitor physical changes that require urgent medical assistance.

The local senior center provides a van that is dedicated to transport senior citizens for medical appointments. However, while she can remain at home, Beth is too frail to use the van service. Compounded by the reality the van stops at Beth's home at 7:30 in the morning; and, generally does not return until late afternoon or early evening. Beth's daughter resides about 40 miles away but calls daily and visits once about every 10 days. She purchases groceries requested by her mother, pays bills and transports her mother to medical appointments.

Upon discharge for the second hospitalization, Beth stayed at her daughter's home for several weeks until more "steady on her feet". When returning home, a volunteer who attends the same church, assists Beth with domestic chores. During the winter county roads may not plowed for several days following snowstorms. In these cases, adult neighbors "check on" Beth; while, younger neighbors are hired for snow removal and yardwork.

Sue, an RN, in the role of case manager found arranging for home maintenance i.e., replacing the broken water pump for the well involved a three-week delay. While the pump was broken, a neighbor brought bottled water to Beth's home. Sue obtained a cushioned recliner-chairlift to make it easier for Beth to get more exercise. Even though Beth's income is below the poverty level, she receives assistance to heat her home through the State's sponsored a fuel assistance program. Beth appears to be quite satisfied with her quality of life, stating; "I thank God every day for my good life, my neighbors and family, and my home health nurse, Sue".

Essentially, her nurse's knowledge about the case management process along with formal and informal resources facilitated a plan of care that allows Beth to "age in place". Without Sue's involvement and nursing expertise, Beth probably would have been hospitalized more frequently and been placed in a long-term care facility.

Healthcare Professional – Community Partnerships

As with case management for a client, professional - community partnerships allow for more effective identification of support structures and services, through the combined efforts and active participation of members of a community. Collaborations may be a new experience for both health care professionals and community participants alike in both the rural and urban context. Working together to resolve mutually identified issues and longstanding problems creates a sense of ownership of the solutions. Hence the question, where do we start and how do we proceed? A brief overview of the process follows in the subsequent paragraphs. It is important to stress that partnership formation generally is not a linear process. Rather, the partners go back, and forth as additional information is obtained about the community or program that is being planned.

Step One: Identify the Problem Area

After a community problem is identified, recruited team of 2 to 5 members with a common interest in addressing a concern. Through dialogue, an informal group often becomes aware of others in the community having similar interests; hopefully, leading to an organized or formal partnership.

Step Two: Assess the Community's Perspective

  • gain the local perspective,
  • assess the degree of public awareness and support for the cause
  • identify special interest groups,
  • identify existing services to avoid duplication of programs,
  • list potential barriers and resources in the community

Community relevant data can be obtained by surveys, personal interviews, publications and articles in the media and official public health reports by the local or state department of health. Always include perspective from community leaders, representatives from local organizations and the, "man and woman on the street". Ideas from community residents and diverse stakeholders are critical elements for planning an effective and acceptable course of action by the community.

Step Three: Analyze the Data

Once the assessment is completed, the data must be analyzed to include identifying and prioritizing the issues of concern. When planning for an acceptable and effective health program or service, compare these concerns with available providers and existing community resources. Identify gaps as well as duplication of services if these exist. Always seek input from relevant community members.

Step Four: Develop a Long-Range Plan

Upon completing the data analysis, one can begin to develop long-range planning activities. For a program to be effective and accepted by the target group(s), involve as many organizations and individual as feasible or interested. For instance, a multi-agency partnership focusing on disparities in hypertension could include the following activities:

  • preparing a list of possible target populations;
  • generating a list of potential community volunteers or professionals who can assist with the project;
  • purchasing essential materials to implement the program;
  • creating awareness among target groups of a program's availability (i.e. marketing) for example populations affected by condition, families, senior centers, faith communities, recreational groups, healthcare professionals, law enforcement personnel and other types of service and civic organizations.
  • Identifying potential funding sources to establish and sustain the program

Step Five: Act

Once the course of action is selected with group consensus implement the plan. Remember, the best laid plans can go awry, especially when working with partners. When planning and implementing a program flexibility is critical as the process generally is dynamic.

Step Six: Program Evaluation

Prior to implementing the initiative, plan the (formative) process evaluation as well as the final outcome (summative) evaluation. These two approaches are critical to measure both short-term and long-term program outcomes. It also is essential to determine if the program is "on track "and if the targeted population's outcomes are appropriately addressed. For instance, an initiative to address the increase in the number of adolescent pregnancies, short-term outcomes might be the total number of people who participate in the program within a specified timeframe. Long-term outcomes, however, may not be obvious for several years or even decades to compare trends. For example, providing responsible sexuality education to junior high students as an intervention to reduce the incidence of teen pregnancies; or, a nutrition education program to prevent cardiovascular disease; or, an integrated occupational safety program to reduce the high rates of vehicles and machinery accidents in a small rural community.

The idiom, hindsight is 20/20, is useful to keep in mind. Choices and best paths may not be obvious from the outset. Allowing for check points with small quantifiable outcomes, the more formal evaluations, and iterative modifications will go a long way to provide services that are accessible, available and acceptable by the target population.

In summary, with improved understanding and knowledge one can identify both opportunities and challenges for professionals who choose to work in a rural setting! This CE offering attempted to highlight social and physical determinants that impact the health of rural populations and common features of the rural health care delivery system. Addressing healthcare access disparities requires that health professionals partner with communities to address the issues.

Characteristics of Rural Nursing Practice

  • Caring for clients/patients (and extended family) across the age span, with a variety of conditions
  • Variety of practice experiences, rather than a specialty area
  • Greater autonomy/independence
  • Opportunity to fully function in one's scope of practice
  • Generalist skills
  • Flexibility; ability to function with sparse resources.
  • Opportunities for Inter-professional practice; Role overlap with other disciplines.
  • Slower paced practice
  • Opportunities for less formal interpersonal exchanges with patients/coworkers
  • Opportunities to participate in community events and organization.
  • Threats to (less) anonymity.
  • (In some instances) defined gender role expectations.
  • Opportunity for creative use of resources.
  • Informal encounters with patients'/extended family outside of the practice setting
  • Highly esteemed/valued status in the community
  • Recognition outside the practice setting

References

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ealth Informaitn HUB

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