2
The Social Environment in Rural America*

RURAL MOSAIC IN AMERICA

From a demographic standpoint, “rural” refers to very small populations and population densities. Although many of those at the workshop are from Iowa or elsewhere in the Midwest, the United States has many types of rural settings different from those in the Midwest. The almost infinite variety of rural areas means that in terms of health issues, policies, and programs, what might work for one rural area may not be adequate for another because the needs of these various rural areas are different, according to Sandra Charvat Burke of Iowa State University.

The U.S. Census Bureau changed the definition of rural between the 1990 and 2000 censuses. According to the 1990 census definition, rural areas consist of towns that have populations of less than 2,500, open country, and people who live on farms (U.S. Census Bureau, 1990). The 2000 census defines “rural” as “territory, population and housing units not classified as urban. Rural classification cuts across other hierarchies and can be in metropolitan or nonmetropolitan areas” (U.S. Census Bureau, 2000a). By using the 2000 census data but the 1990 census definition of rural, 55 million people live in rural areas in the United States (according to the 2000 census definition, 59 million people live in rural areas) (U.S. Census Bureau, 2000a). In essence, these figures mean that about 20 percent of the U.S. population lives in rural regions, said Burke.

The percentage of rural dwellers varies greatly by state. For example, Vermont has the highest proportion of rural residents—almost 62 percent of the total

*  

The views expressed here do not necessarily reflect the views of the Institute of Medicine, the Roundtable, or its sponsors. This chapter was prepared by staff from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics.



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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary 2 The Social Environment in Rural America* RURAL MOSAIC IN AMERICA From a demographic standpoint, “rural” refers to very small populations and population densities. Although many of those at the workshop are from Iowa or elsewhere in the Midwest, the United States has many types of rural settings different from those in the Midwest. The almost infinite variety of rural areas means that in terms of health issues, policies, and programs, what might work for one rural area may not be adequate for another because the needs of these various rural areas are different, according to Sandra Charvat Burke of Iowa State University. The U.S. Census Bureau changed the definition of rural between the 1990 and 2000 censuses. According to the 1990 census definition, rural areas consist of towns that have populations of less than 2,500, open country, and people who live on farms (U.S. Census Bureau, 1990). The 2000 census defines “rural” as “territory, population and housing units not classified as urban. Rural classification cuts across other hierarchies and can be in metropolitan or nonmetropolitan areas” (U.S. Census Bureau, 2000a). By using the 2000 census data but the 1990 census definition of rural, 55 million people live in rural areas in the United States (according to the 2000 census definition, 59 million people live in rural areas) (U.S. Census Bureau, 2000a). In essence, these figures mean that about 20 percent of the U.S. population lives in rural regions, said Burke. The percentage of rural dwellers varies greatly by state. For example, Vermont has the highest proportion of rural residents—almost 62 percent of the total *   The views expressed here do not necessarily reflect the views of the Institute of Medicine, the Roundtable, or its sponsors. This chapter was prepared by staff from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics.

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary population—whereas California and Nevada each have less than 10 percent (U.S. Census Bureau, 2000a). However, the percentage for Nevada can be misleading because there are vast areas of open country in Nevada consisting of sagebrush and desert where no people live, noted Burke. In contrast, Iowa’s rural areas have a small town almost every 10 miles. Thus, the meaning of “rural” for Iowa and Nevada is very different, noted Burke. The Office of Management and Budget offers another way of looking at “urban” and “rural” by distinguishing between “metropolitan” and “nonmetropolitan” counties. If there is a city of 50,000 people or more, that city and the entire surrounding county are considered a part of a metropolitan county. If a county does not have a city of 50,000 or more but sits next to a county with such a city and more than 25 percent of its population commutes to that city, then that county is considered part of the metropolitan area as well. On this basis, Iowa has 20 metropolitan counties and 79 nonmetropolitan ones. Burke noted that if these definitions were applied to California and Nevada, they would each have many metropolitan areas. In Nevada, for example, the metropolitan area of Las Vegas takes in the entire county, and whereas counties in Iowa are each about 30 square miles, Nevada’s counties are significantly larger by comparison. The metropolitan area of Las Vegas comprises a lot of unsettled desert. The same is true of southeastern California, where counties with large areas of desert would qualify as metropolitan counties because they have or are adjacent to a city with a population of more than 50,000. Burke noted that the rural population can be counted on the basis of agricultural output: The individuals must live on at least one acre of land and sell at least $1,000 of agricultural products per year to be counted as rural. Using this definition, the 2000 census showed that in the United States less than 3 million people, or approximately 1.1 percent of the U.S. population, live on farms. Therefore, the majority of people in the United States are not intimately associated with a farm and may not have an understanding of what happens on a farm, food production activities, or the problems that farmers face, said Burke. Today, less than 6 percent of Iowa’s population lives on farms, and farming is a smaller part of rural life than it has been in the past. Not only are fewer people living on farms, but even if they live on a farm, many are working off the farm for their incomes. A U.S. Department of Agriculture (USDA) survey of farmers indicates that for about 33 percent of farm households, neither the farmer nor the farmer’s spouse works off the farm, which means that for almost 70 percent of farm households, somebody—either the farmer or the farmer’s spouse, or both—works off the farm (USDA, ERS, 2005). Consequently, the majority of the income for even the very small proportion of the U.S. population engaged in farming is coming from off-the-farm sources, noted Burke. Interestingly, she noted that one of the reasons given for off-farm work was that the employment was a way of obtaining health insurance (Figure 2-1).

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary FIGURE 2-1 Reasons why farmers must find a job off the farm. SOURCE: USDA, ERS (2005). Population Change in Rural Areas The demographics of the populations in rural areas in the United States also differ. In Iowa, many counties have had and continue to have declining populations, but other nonmetropolitan areas in the western part of the country are growing rapidly. Burke noted that as the population increases, the health care demands in those areas differ from those in areas experiencing population declines. Maps prepared by the USDA Economic Research Service (ERS) show that some counties in Iowa have above-average population growth of at least 13 percent (USDA, ERS, 2005). Other such areas can be seen in northern Michigan, Minnesota, and throughout the South and Southeast. However, areas in the Central Plains and some areas in Iowa had no population growth or had population declines between 1990 and 2000. Therefore, the population declines seen in some parts of Iowa do not reflect what is happening in other nonmetropolitan areas around the country, said Burke. The nonmetropolitan counties where the population declined between 1980 and 1990 and again between 1990 and 2000 are in Appalachia and an area stretching from the Texas panhandle north through the northern Great Plains to the Canadian border.

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Health Care in Rural Areas Metropolitan and nonmetropolitan areas also have different economic activities, and these differences have effects on access to health care. Counties that remain dependent on agriculture and farming—that is, areas where 50 percent or more of total county earnings are derived from agriculture according to USDA’s Economic Research Service (USDA, ERS, 2005)—tend to be those that have also continued to show population declines. Families in those counties in rural areas may not have access to health care because they are self-employed on their farms or in some other business and therefore have no health plan provided by an employer. In addition, Burke indicated that the health needs of populations in mining-dependent counties, historically in Appalachia, Texas, and the West, differ widely from those in farm-dependent counties because of the presence of different diseases and chronic illnesses. Starting in the 1970s, manufacturers moved to rural areas, particularly in the South, the Midwest, and some central states. Therefore, in some counties in those states, a large number of people are employed in manufacturing. These manufacturers, if they are large, may provide coverage for health care, but others do not or the insurance may be very expensive for the employee. Other counties receive a high proportion of income from employment with federal and state governments, and yet some others—although these are significantly fewer in number—may derive their income mainly from retail, finance, and real estate services. Finally, some counties are not differentiated on the basis of economic activity; these are considered nonspecialized counties. A special type of county is the recreational or tourism county. There are not many of these in Iowa. Mostly, these areas are around the Great Lakes; in the Northeast; and in the West, where there are mountains. Recreational counties may be very seasonal, depending on the kind of recreational activities that they offer, so they may have many visitors at certain times of the year and few at others, noted Burke. As a result, these counties may experience seasonal peaks and troughs in health care demand and have a particular need for special types of health care services, such as those needed to treat people involved in accidents. Finally, retirement, although it is not an economic activity, has also influenced the economics and health care situations in various parts of the country. Contrary to popular belief, states where people go for their retirement are not only in the Southeast (Florida) and Southwest (Arizona, New Mexico, and Texas), but also include Minnesota and Wisconsin. Retirees bring with them a whole set of health issues, such that counties with a high proportion of older people have health care delivery needs that differ from those in the rest of the country and may also have seasonal populations if the weather is uninviting during part of the year, such as in Arizona during the summer, said Burke.

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Socioeconomic Aspects in Rural Areas Other socioeconomic aspects differentiate metropolitan and nonmetropolitan areas. The former, for example, tend to have a higher proportion (by 4 or 5 percentage points) of people who have completed high school. The difference is even higher in terms of the proportions of people with a college education. Higher levels of education and higher rates of high school completion, in turn, correlate with a lower prevalence of poverty, less unemployment, and greater access to health care. In Iowa, the problem is not that people are not being educated at the college level. The problem is that young graduates move out of the state or to metropolitan areas upon graduation, noted Burke. Nonmetropolitan areas also tend to have slightly lower rates of employment than metropolitan areas. As is the case for education and poverty, areas that tend to have low rates of employment tend to have a low proportion of well-educated people. The same is true of income. The median annual household income in nonmetropolitan areas lagged $11,000 behind that in metropolitan areas in 1999. As would be expected, the rate of poverty in nonmetropolitan areas tends to be higher than that in metropolitan areas, and those counties where the population has low levels of education and low rates of employment are the ones with the highest poverty rates (i.e., 20 percent or more of the population is below the poverty level). In addition, pockets of poverty persist in various parts of the country. Also, as some workshop participants noted, more than 46 percent of land in Iowa is owned by women and the number of female ownership is growing partly because women live longer. A lot of resources in Iowa will be changing hands disproportionately in the near future because, according to a participant, currently the average age of farmland owners in Iowa is over 65. Age Disparities in Rural Areas Nonmetropolitan areas tend to have a higher proportion of people older than 65 years of age. One of the reasons for this disparity is that nonmetropolitan areas have had more outmigration of youth. In some areas of Iowa, there has also been the loss of people 65 years of age and older. A small cohort of births occurred during the Depression, before World War II and the Baby Boom. During the Depression, people postponed weddings and having babies, and as result, the birth rates were historically low. That small cohort of individuals born just before the Depression is smaller than the preceding generation and the Baby Boom generation that came after it. That small cohort of individuals is the one that has become age 65 and older in recent years. Thus, in the current decade, the older people died off and those entering the 65-plus age category are a smaller group, noted Burke. Once the large cohort of Baby Boomers starts turning 60 and 65, the cohort of older people will increase as Iowa is already a leading state in the nation in terms of aging population.

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Ethnic Diversity in Rural Areas Nonmetropolitan areas tend to have less ethnic diversity and smaller minority populations—that is, any race other than white—than metropolitan areas, although in this regard there are major differences among nonmetropolitan areas. For example, Alaska shows a high percentage of Native Alaskans, whereas certain areas of the West have large Native American populations that were forced to migrate there. These populations have mostly remained in the same areas and retained their proportion of the total local population between 1990 and 2000. Asians have also continued to settle for decades in the same areas where their ancestors first located, mainly the West Coast and Hawaii. Similarly, from a historical perspective, African Americans have concentrated in metropolitan and nonmetropolitan counties in the South and some other metropolitan areas around the country, but other nonmetropolitan areas continue to have very few African Americans. In Iowa, as in much of the Midwest, African Americans are largely in metropolitan areas. Hispanics from Mexico historically settled in the Southwest, Cubans settled in Florida, and Puerto Ricans settled in the Northeast. In the central region of the United States, many counties had less than 1 percent Hispanics as recently as 1990. By 2000, however, the change in some areas was dramatic, largely because of opportunities for employment in food-processing industries. In Iowa, Kansas, Nebraska, and Minnesota, the proportion of Hispanics has risen rapidly in counties with meat-packing plants. In seven Iowa counties, this increase reached 1,000 percent between 1990 and 2000, so that cities such as Marshalltown and Storm Lakes now have proportions of Hispanics of 15 percent and 20 percent, respectively. A large increase in the Hispanic population can be seen in North Carolina and Arkansas as well, where the proportion of Hispanics increased by more than 300 percent from 1990 to 2000. Burke concluded that while the patterns for Native American, Asian, and African American populations did not change radically from 1990 to 2000, the size of the Hispanic population changed dramatically across much of the country. LANGUAGE, CULTURE, AND HEALTH The issue of demographics is a serious one for Iowa, said John-Paul Chaisson-Cardenas of the Iowa Division of Latino Affairs. The general population of Iowa—the Caucasian population—is growing older, there is a brain drain out of colleges and universities, and the entire labor force will need to be replaced in some communities. In 2000, there were 32.8 million Latinos in the United States, equivalent to approximately 12 percent of the total population (U.S. Census Bureau, 2000a). This proportion had grown to 13 percent by 2004, with steady growth that will continue through the years. The changes taking

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary FIGURE 2-2 Growth of the Latino population in the United States from 1990 to 2000. In 1990, Latinos fromed the largest minority in 13 states and by 2000 grew to become the largest minority in 23 states. SOURCE: U.S. Census Bureau (2000a). place consist of not only the size of the Latino population, but also the locations where that population chooses to live (Population Resource Center, 2005). In 1990, Latinos were the majority of the minority—the largest minority group—in 13 states; by 2000, this number was 23 states and included Iowa (Figure 2-2) (Ramirez and de la Cruz, 2002). All but one Iowa county had growth in the Latino population between 1990 and 2000, and although the overall growth was 153 percent, in seven counties that growth was over 1,000 percent. As a result, a culture and a language different from those of the predominantly white population are becoming part of Iowa and will influence Iowa’s future development. With the growth in the Latino population emerges a subpopulation of students with limited proficiency in English. This means that the number of Latino students in Iowa schools from preschool through grade 12 grew by 425 percent between 1985 and 2002. In contrast, there was a negative growth (−7 percent) in the propor-

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary FIGURE 2-3 Growth curves for the Hispanic and the white populations. SOURCE: Ramirez and de la Cruz (2002). tion of white students during the same period of time (Iowa Commission, 2004). Although it is hard to assess the number of non-English-speaking Latino adults and Latino adults with a limited proficiency in English, because these schoolchildren have parents or guardians it can be assumed that there are many non-English-speaking Latino adults, and this begins to paint a picture of Iowa different from that which most people perceive, noted Chaisson-Cardenas. In addition, as the demographics of the population in Iowa’s schools change, so does the population that will be the service providers in Iowa in the future. There is a tendency to think of Latinos as immigrants, and indeed, a good proportion of them are, noted Chaisson-Cardenas. However, it is frequently forgotten that Latinos are also a native-born population of the United States and have been since before the United States became a country. As a result, the significant changes in the ethnicity of the population of Iowa result not only from immigration but also from migration from other states. The growth pyramid for the Latino population is significantly different from that for the Caucasian population. Whereas the graph in Figure 2-3 exhibits a bulge contributed by the Baby Boom generation, which corresponds to the group that is now 41–59 years old, the pyramid for the Latino population shows a large group in its 20s (Ramirez and de la Cruz, 2002). The average age of Latinos is 23 years, a prime reproductive age, indicating that this population will create the most growth in Iowa for at least the next 15 years (Figure 2-3) (Ramirez and de la Cruz, 2002). This should be taken into account as part of the process of

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary planning for Iowa’s environmental health, but this is not being done at present, indicated Chaisson-Cardenas. Latinos are disproportionately affected in many areas of health. Thus, 50 percent of Iowa’s Latinos do not have health insurance, and they are much more likely than other groups to become diabetic (Iowa Commission, 2004). Young Latino women tend not to receive the prenatal care that they need. The result is an environment in which the institutions created to serve other people are not responding adequately to the growth of the new population. One significant reason for the unresponsiveness of the health care system to the needs of Latinos is a lack of “cultural competence,” defined as the ability of a professional to be effective with a client who is of a cultural background different from his or her own, said Chaisson-Cardenas. However, some participants noted that different cultures expect different things from their professionals. For example, in some cultures patients expect doctors to tell them what to do rather than being given options and being part of the decision-making process. Culture and language are not barriers by themselves; they are simply part of each person’s background and the way in which each person was raised. These factors weigh heavily on that particular relationship that must be established between professional and client, doctor and patient, police and civilian, and researchers and those whom they are trying to study. In such a relationship, it is the burden of the professionals to adapt to the culture of the people they are trying to serve. For example, if a Latino is seeking help from a mental health professional and the professional does something that insults the patient or breaks the relationship so that the two individuals cannot build a rapport, the breakdown is not a result of the patient’s Latino culture but rather a result of the professional’s lack of skills. Is the professional using the appropriate methodology or the appropriate skills that are needed to be effective with the patient? In other words, if the doctor or nurse cannot treat somebody as a patient because he or she cannot speak the person’s language, that is not the fault of the language or the patient but rather a result of a lack of skills on the part of the professional, and that particular skill is language—a communication skill, suggested Chaisson-Cardenas. In addition, cultural competence is a responsibility not only of the individual but also of the entire system. If the population changes, the system must adapt to the change. It then becomes necessary to examine the effectiveness of the system that is treating people who are culturally different from the majority population. This reevaluation is needed in the areas of mental health, general health care, public health, how programs are coordinated, and what research is being done. When professionals try to research Latinos, they often do not have the base level of cultural competence, and their research comes out flawed because they have not reached the population that the research was supposed to reach. Therefore, cultural competence should be viewed as a premise for achieving effectiveness, said Chaisson-Cardenas.

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary The issue of language was identified in Iowa more than 30 years ago. A report published in 1979 documented the need for interpreters, particularly in health and in the courts (Conóceme en Iowa, 1979). It took about as many years to pass legislation that established standards for qualified interpreters, according to Chaisson-Cardenas. The Interpreter Bill was finally passed in 2004. That legislation gave the state government jurisdiction in setting qualification standards for language interpreters in social services, mental health, general health, the courts, and administrative agencies. The bill recognized the fact that if one cannot communicate as a professional with the client, the tool that a professional needs to become effective is a qualified interpreter—just as much as the professional needs a stethoscope to effectively listen to the patient’s heart. The interpreter, sometimes consciously and sometimes unconsciously, serves as a cultural mediator, because more information than just words to be translated is being collected. The interpreter is able to collect information through body language, context, and perhaps familiarity with the patient’s cultural background and interpret that information for the physician. However, many people forget that the interpreter is nothing but a tool; and if one is to focus as a professional, one needs to use all his or her skills—rapport-building skills—and use them directly with the person one is trying to serve, said Chaisson-Cardenas. Nevertheless, the professional tends to focus on the interpreter, and he or she must be taught how to divert his or her attention from the interpreter to focus on the person being served, much in the way that a physician is taught how to use a stethoscope. People become impatient with interpreters because their use as part of caregiving is tiring, and interpreter fatigue is also a problem. (It has been demonstrated that the longer an interpreter translates, the lower the quality of the translation [House, 1997]). Other interpreter-related issues are evaluations of interpreter performance and the qualifications of interpreters. Iowa has not had a mechanism to qualify interpreters, although some hospitals have dealt with this issue, noted Chaisson-Cardenas. With the new Interpreter Bill, Iowa will put in place a system that actually measures the technical proficiencies of interpreters and second-language speakers. In conclusion, language and cultural competence are skills that put the focus of responsibility on the professionals, not on the clients. Those professionals who gain such skills become more marketable and much more effective in the long run than those who do not. RURAL INFRASTRUCTURE: ENVIRONMENTAL HEALTH AND BEYOND As mentioned above, some significant differences exist between rural and urban populations and between rural and urban health care delivery systems. When actions at the local rural community health level are planned or information on national policy decisions with implications for rural health is sought, it is

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary important to understand the unique characteristics of rural communities, their environments, and the conditions under which health care is delivered to rural populations. This means the consideration of factors as varied as population density, the remoteness of a community from large urban areas, the characteristics of the local workforce—and, even more specifically, the characteristics of the rural health care workforce—and the cultural norms of the region, all of which influence health and health problems that rural communities face, said Mary Wakefield of the University of North Dakota. Rural areas tend to have a higher proportion of older residents. This difference, by itself, has immediate implications for the rural health care infrastructure, as well as for the infrastructure of the broader community. Thus, elderly individuals have a greater need for health care services related to chronic disease management and long-term care, and this affects the specific types of health care that are available, noted Wakefield. As an example, some rural communities have an infrastructure of cardiac or stroke rehabilitation facilities but lack an obstetrics unit that would be available in a larger city. Therefore, even the basic infrastructure of health care manifests itself differently to serve the needs of different populations in rural communities. Another example is evidence of differences in health behaviors between rural and urban populations. Individuals in rural areas exhibit poorer health behaviors, as shown by their higher rates of smoking, higher rates of obesity, and lower rates of exercise, noted Wakefield. The bucolic myth of the fit, trim farmer is often just that, a myth, because many individuals who live in rural areas are not farmers, and many of them are not trim. Rural environmental characteristics, such as the mechanization of farm work and the features of the built environments of small towns—which typically do not include the fitness facilities or the bicycle trails that might be found in an urban landscape—combined with a motorized way of life, necessary to traverse long distances even for children to go to school, contribute to decreased levels of physical activity. Therefore, there are important links between rural population characteristics, the health of individuals and rural communities, and the infrastructure that surrounds them. Those features can often be quite different between rural and urban areas. The bucolic myth of the fit, trim farmer is often just that, a myth, because many individuals who live in rural areas are not farmers, and many of them are not trim. —Mary Wakefield To respond to health care challenges such as obesity in many rural communities, one would generally find strategies that are used in a personal health care delivery system, as opposed to a population health approach, noted Wakefield. Hence, one would likely see a focused health care system response to deal with an individual who is overweight or obese. This focus might be on the use of a dietitian to counsel the overweight or obese individual about dietary intake and

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary meal planning. To move from a personal to a population health approach or orientation, it would be necessary to engage a group of different stakeholders, in addition to the dietitian, including, for example, public health and environmental health professionals as well as community planners. Thus, in addition to interventions such as meal planning targeted at individuals, the built environment of rural communities could also be modified in meaningful ways to influence the occurrence of overweight, obesity, and comorbidities across rural areas, with a sought-after outcome of positively influencing population health. Wakefield pointed out that the health care systems in many rural communities truly struggle to sustain their vitality. For too long those involved with the rural health care infrastructure have been excessively focused on the bricks and mortar and the activities that go on inside hospitals and clinics and have not focused enough attention or connected to other sectors within rural communities sufficiently to influence not just the individual’s health but the health of the entire community as well. Part of the reason for this has been the difficult challenge facing health care providers in rural communities because their health care infrastructure is financially fragile owing to the difficulties in attracting even an adequate health care workforce. Consequently, it is and has historically been very difficult to invite health care providers to step outside their traditional role inside a health care system—where they are delivering individualized health care—and ask them to step back and conceptualize how they can improve the health of the members of the community by working in tandem with other sectors. Strategies to Link Health and the Rural Environment Health care for communities needs to be addressed by the use of a much broader, population-focused approach, said Wakefield. To start the movement toward a broader community health care approach, the Institute of Medicine (IOM) recently released the report Quality Through Collaboration: The Future of Rural Health (IOM, 2004), which discusses the need to engage other sectors and focus on community health by addressing issues that include environmental health, business, agriculture, and education. The IOM report begins to build a platform designed to strengthen rural health and the rural environment by meaningfully linking relevant dimensions of the built, the natural, the social, and other environments that characterize rural America and proposes five strategies to achieve that end, noted Wakefield. One of the five strategies proposed to improve the quality and infrastructure of health care in rural communities is to adopt an integrated, prioritized approach to address personal and population needs at the community level. The second of the five strategies proposed in the IOM report is the establishment of a stronger quality improvement support structure to assist rural health systems and professionals. The third strategy that can be used to address and strengthen the health

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary care infrastructure in rural communities focuses on enhancing the human resource capacity of rural communities, including the education, training, and deployment of health care professionals and the preparedness of rural residents to actively engage in improving their own health and health care. Therefore, when talking about health care in rural communities, the report suggests not only that the traditional health care environment and health care workforce need to be considered, but also that new, creative, and innovative ways of making rural residents part of their own infrastructure for ensuring access to high-quality health care need to be found. The fourth strategy, monitoring and ensuring that rural health care systems are financially stable, addresses a problem that has a collateral impact on the rural community, in the sense that without a strong health care infrastructure, the economic health of the community may be compromised. Thus, businesses may decide not to locate in those communities or businesses in those communities may decide to relocate away from those communities on the basis of the availability of a health care infrastructure for their employees. Similarly, some senior citizens may decide whether to stay in a rural community or move on the basis of the availability of an appropriate health care infrastructure. As a result, the rural health care sector is tightly linked in important ways to the economic health of rural communities, thereby highlighting the importance of ensuring the financial stability of rural health care systems. Finally, the fifth strategy for ensuring an adequate health care infrastructure in rural communities outlined in the IOM report revolves around investing in and building information and communications technology infrastructure. The rural health sector is tightly linked in important ways to the economic health of rural communities, thereby highlighting the importance of ensuring the financial stability of rural health care systems. —Mary Wakefield Of the five strategies proposed in the IOM report, three can be woven into the discussions of environmental health: (1) the focus on personal and population health, (2) the health care workforce, and (3) building access to information and communication technology. Personal Versus Population Health Approaches An overriding theme of the first strategy—personal and population health needs—in the IOM report is the view that rural communities should focus greater attention on improving population health, in addition to meeting personal health care needs. This theme was arrived at through recognition of the fact that health care is only one of a number of determinants of the health of individuals, families, and communities, although access to high-quality personal health care services does increase health and helps to reduce disease. Other important deter-

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary minants of health status in communities include behaviors; environmental exposures and threats; and social circumstances, such as educational level and socioeconomic status. Therefore, expansion of the focus on health and health care to include facets of that broader infrastructure can have a major impact on community health, said Wakefield. As a corollary of this principle, the IOM report concluded that health care providers share responsibility with other groups, such as consumers, educators, employers, governments, and religious organizations in rural communities, to work together to achieve positive population health outcomes. Similarly, the local rural infrastructure should reflect collaborative efforts at the community level to create environments that minimize the likelihood of illness or disease and to provide incentives to residents of rural communities to pursue healthier lifestyles. This reorientation of personal to population health needs and the need to engage other sectors for a broader approach to rural health are consistent with IOM’s concept of quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes,” (IOM, 2004) noted Wakefield. Consequently, a population health focus needs to be built into the decision making of the health care sector as well as that of other sectors of rural communities, such as the community and environmental planning sector and the educational system, as well as rural cooperatives concerned about a strong rural community. An essential vehicle for accomplishing these goals is collaboration across sectors. The IOM report made various recommendations regarding how the suggested strategies could be tested. One recommendation was that federal funding should be made available to support comprehensive health care system reform demonstration projects in a limited number of communities. These demonstration projects should evaluate alternative models for achieving greater integration of personal and population health services and developing innovative approaches to the financing and delivery of health care services. The new models or prototypes—which should be funded at the federal level and engaged at the local level—should use an integrated approach to improving health care by tying in more tightly and seamlessly the various elements of the rural infrastructure. The purpose of the suggested demonstrations called for in the IOM report is to achieve six quality aims for improving health care delivery systems in rural and urban areas alike: The care that people receive should be safe, effective, patient centered, efficient, equitable, and rendered in a timely manner, indicated Wakefield. Historically, these aims have been directed almost exclusively at the personal health care delivery system, that is, hospitals, doctors, clinics, nursing homes, and the like. The report takes those concepts to the community and population health system levels. Thus, whereas safety in a hospital means that the patient seeking care is not injured, safety in the community context might mean the adoption of measures that include the avoidance of accidents or inju-

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary ries that commonly occur in rural communities or rural areas because of compromises in the environmental, occupational, and recreational areas as well as other areas of safety. Adoption of these measures, in turn, might require the adoption of a variety of community planning strategies for improving community-level safety, ranging from the measurement of toxic exposures to the elimination of environmental hazards and the enhancement of traffic safety. Rural Health Care Workforce Many external forces impinge on rural communities today, such as government policies, urban issues that are generalized to rural communities, and payment policies. For this reason the IOM report discussed the need for strong leadership to address not only what is going on within rural communities but also those events in the external environment influencing the health status of rural communities, noted Wakefield (IOM, 2004). For example, it is essential to field educated individuals who have management skills and knowledge, some background in community planning and collaboration, a knowledge of epidemiology, and exposure to social and environmental services to practice and work in rural communities, as all of these areas are important to community health leaders. Therefore, the report covered such topics as combined degree programs that diverge from the traditional, narrowly focused programs that have historically prepared health care providers. This implies that students need to work, practice, and live in rural communities to acquire a much broader context than has historically been the case. Building Access to Information and Communication Technology The third strategy discussed in the IOM report that could be best woven into rural health today deals with information and communication technology (ICT), which requires a community-based approach that uses public as well as private resources across sectors. To build an ICT infrastructure, the focus must be not only on the health care sector but also on expanding beyond the health care sector to other sectors in local rural communities, such as educational and regional businesses that could also benefit from a stronger communication and information infrastructure. Because the growth of ICT in some rural areas often lags behind that of their urban counterparts, the “digital divide” for health care and other sectors in rural communities is becoming one of the greatest challenges to the rural infrastructure, according to Wakefield. As part of its ICT-related recommendations, the IOM report focused on the inclusion of a rural component in the plans of the National Coordinator for Health Information Technology, a new position created by Executive Order in 2004 and housed within the U.S. Department of Health and Human Services (Executive Order, 2004; ONCHIT, 2005). The report emphasizes the fact that a

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary rural component is necessary because whatever is designed for urban areas will likely not be fit for rural communities. The report also recommended that all rural communities be provided with high-speed access to the Internet and offered details on how that can be accomplished. In addition, the report called for the fostering of information and communication collaborations and demonstrations in rural areas. Finally, the report recommended the provision of ongoing educational and technical assistance to rural communities to make the best use of ICT. A journalist once said, while capturing the challenges and excitement during the formation of the European Union: “We all share the same sky, we just have different horizons.” “What a much better picture of the landscape we would have if we were able to seamlessly share our various views of those horizons,” concluded Wakefield. RURAL MENTAL HEALTH: A MULTIFACETED ISSUE Mental health is a facet of health that undergirds the vitality of all rural life. The problems associated with mental health in rural areas have many facets, and as a result, many people, institutions, and organizations work diligently to improve the social and mental health of rural Iowa and rural America, said Cecilia Arnold of the Ligutti Rural Community Support Program. Perhaps the best way to examine these many facets of rural mental health is through a review of the overall situation in rural areas that affects the mental health of rural dwellers and then through a specific look at depression and three population groups. Factors Affecting the Mental Health of Rural Dwellers In rural Iowa, as in many other states, the farming population is declining because of changes in agriculture and fragile economic systems. Those who remain are increasingly isolated, noted Arnold. The average age of farmers is the mid-50s. Farm children are not encouraged by what they observe and tend to plan their future in urban areas or out of state. Farm couples today often work off the farm to make ends meet, and more often than not employers are several miles away. This implies transportation costs that affect the family budget. Accessibility to needed services and work is difficult without reliable transportation systems. The available jobs, in turn, are part-time and offer low pay; even full-time jobs provide low pay and often do not offer basic benefits, let alone comprehensive health care coverage that would include mental health treatment, indicated Arnold. Moreover, when large corporate retailers move into small communities, local businesses can seldom compete and are forced to close. The percentage of working poor in rural areas is higher than that in urban areas, and, in general, rural areas have more poverty, said Arnold. Services like

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary law enforcement, emergency medical services, domestic violence shelters, and mental health services have diminished in rural areas, whereas social problems, such as the scourge of methamphetamine use, have taken hold. The culture of rural states such as Iowa tends to be one of self-sufficiency, traditional values, and patriarchal social structures. —Cecilia Arnold The culture of rural states such as Iowa tends to be one of self-sufficiency, traditional values, and patriarchal social structures. Rural residents represent several generations who embrace these and other cultural characteristics with varying degrees of intensity. The population of Iowa is now more diverse as a result of the immigration and migration of people from many cultures, who face discrimination along with the challenges of assimilation. All these facets of rural life point to the challenges that can distress individuals, families, and communities and act as a catalyst to mental health problems, noted Arnold. Sixty percent of rural areas in the United States are designated areas with a shortage of mental health professionals; most of Iowa’s rural counties have that designation. Regrettably, Iowa does not have data on the incidence or the geographic locations of mental illness in the state, noted Arnold. The existent data cover only those individuals receiving public pay assistance. Complete data would be invaluable for research and to help better serve mentally ill individuals in the state. Rural Mental Illnesses: Depression Looking at a general picture of rural mental illnesses—and at depression in particular—the report of the Rural Women’s Work Group of the Rural Task Force of the American Psychological Association (APA) and the American Psychological Association’s Committee on Rural Health (APA, 2005) describes the mental health care needs of rural women. Suicide rates, particularly in the rural west of the United States, are as many as three times those in urban areas. Forty-one percent of rural women, as opposed to 13 percent to 20 percent of urban women, report high levels of anxiety and depression (APA, 2005). Regardless of the importance of depression in the overall burden of disease, a study conducted with medical outpatients reported that depression was accurately diagnosed in less than one-half of community and primary care settings (Attiullah and Zimmerman, 2003). Similarly, when they were interviewed as part of an ongoing study, rural physicians in east-central Iowa admitted feeling ill-equipped to diagnose and treat depression. Moreover, they were unaware of the best practices for the treatment of the illness. These same providers are generally overburdened from the running of their rural practices and are vulnerable to distress and depression themselves, noted Arnold.

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Clergy are in a similar situation and admit to being at a loss in dealing with mental illness. This is a troublesome admission, considering that members of the clergy are seen as the individuals who are the most likely to be approached by someone in distress, especially in rural regions. Consequently, education about intervention and mental illnesses needs to be readily available to health care and helping professionals, consumers, family members, and the community to change practice patterns, reduce the stigma of mental illness, and improve the outcomes for those with mental illnesses such as depression, said Arnold. This approach would encourage rural dwellers to seek help sooner. It is noteworthy that rural people tend to enter mental health treatment later in the course of disease than their urban counterparts and remain sick longer and at a higher cost compared with the length of illness and the cost of treatment for their urban counterparts (Mohatt, 2003). The ability to pay is also a factor in early intervention. A study of Wisconsin farmers indicated that the majority were underinsured (PATS, 2002). The Kaiser Commission on Medicaid and the Uninsured says that farmers are 10 times more likely to self-purchase insurance and to have limits on coverage and are less likely to seek preventive services than the general population (Ziller et al., 2003). Depression is linked to a host of social problems, such as suicide and domestic violence, and the latter is a problem in Iowa, as it is in other states (Hegarty et al., 2004). In small communities, where most people know one another, danger lurks for the victims of domestic abuse. The perpetrator is known and may have friends among local law enforcement personnel and residents, who avoid getting involved in what is seen as a private matter, noted Arnold. Therefore, the proper and early diagnosis and treatment of depression may go a long way toward avoiding more serious problems, like violence in the home. Education in self-care is another avenue that can be taken to avoid episodes of some types of depression, whereas the examination of environmental impacts may open the door to more prevention. The Department of Psychology at Colorado State University conducted a survey of a cross-section of farm couples in northeastern Colorado and assessed them for depression and pesticide poisoning (Stallones and Beseler, 2004). The conclusion was that exposure to pesticides at a concentration high enough to cause reported poisoning symptoms was associated with high rates of occurrence of the symptoms of depression, independent of other known risk factors for depression, among residents, said Arnold. Those who self-reported pesticide exposures at the level that would cause poisoning were almost six times more likely to have symptoms of depression. This points to the need to do more research about the effects of pesticides and other environmental exposures on mental health. Another prominent issue in rural America is the abuse of methamphetamine, a drug that is very dangerous to manufacture and seriously addictive. A meeting of the National Catholic Rural Life Conference in early November 2004 listened to various anecdotal reports from farmers and clergy in Kansas, North Dakota,

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary Ohio, Wyoming, and Wisconsin about the proliferation of methamphetamine in rural areas of their states. In growing numbers, the parents of addicted individuals and those incarcerated for methamphetamine-related crimes are raising their grandchildren. In response to this problem, Iowa has begun a program called Meth Watch, a collaborative effort among government, retail, law enforcement, and religious leaders. The program works by limiting access to the common ingredients for the manufacture of methamphetamine and providing information on such purchases to law enforcement. Rural Mental Health in Selected Populations Specific factors affect the mental health of various population groups in rural America. The first of these groups is the elderly. According to the 2000 U.S. census, the age group 80 years old and over is increasing more rapidly than any other age group in the country (U.S. Census Bureau, 2000a). Iowa’s proportion of older adults in the population exceeds that of the United States as a whole: It is second in the nation in the percentage of individuals 85 years of age and older, third in the nation in the percentage of people 75 years of age and older, fourth in the percentage of individuals 65 years of age and older, and fourth in the proportion of those 60 years of age and older (U.S. Census Bureau, 2000a). A statewide assessment of noninstitutionalized older Iowans ranging in age from 60 to 104 years, conducted by the Iowa Department of Elder Affairs (IDEA) Area Agencies on Aging and Iowa State University, indicated that older Iowans do not tend to be poor, although 20 percent have annual incomes below $10,000 (IDEA, 2005). The older a person becomes, the more likely that the individual has an income below the poverty level. Older women living alone are more likely to be in the category of individuals with annual incomes of $10,000 or less (U.S. Census Bureau, 2000a). Sometimes, as a consequence of advanced age and illness, an individual requires care, said Arnold. As a profession, caregiving in nursing homes and home settings provides low wages and, often ironically, no benefits. In other cases, family members must quit their jobs to become full-time caregivers for a loved one, and although caregiving has its rewards, when a loved one requires extensive care and supervision, caregiving can become considerably stressful, noted Arnold. The caregivers of individuals with cognitive impairment are at an elevated risk of clinical depression. A comparison of elders who served as caregivers for their spouses and elders whose spouses did not need care indicated that the caregivers had a mortality rate 63 percent higher than that of the non-caregivers (Schulz and Beach, 1999). Similarly, the Geriatric Mental Health Foundation (2003) reports that elderly caregivers with histories of chronic illness of their own have a higher mortality rate than their noncaregiving peers, something that has led some doctors to describe such caregivers as “the hidden patient.” Professional caregivers also experience stress from such factors as fa-

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary tigue, low wages, and long hours, which can lead to the actual abuse of the patient or loved one, noted Arnold. The second population worthy of examination in relation to rural mental health is the immigrant and migrant sector. As noted earlier, Iowa is home to a rapidly increasing Latino population that has come to the state to provide for their families, generally by working in the meatpacking industry. Assimilation is not easy in the best of circumstances, but Hispanic immigrants and migrants working in rural areas have had to face other difficulties, including discrimination (Soto, 2000). According to Arnold, some have been the victims of traffickers, who put them into positions of servitude (Swanson, 2005). Adequate housing has been difficult for them to secure. In addition, they miss their families, who are often left behind. All of these circumstances are setups for a host of mental health problems, and there are few therapists who speak Spanish to work with them, noted Arnold. The third population is one that constitutes an emerging concern: the National Guard members and reservists returning from the war in Iraq. Many rural residents join the National Guard to supplement their income. A study by Hoge and colleagues (2004) showed that one of every five combat soldiers leaving Iraq does so with a mental illness. With access to health care in rural Iowa diminished, the choice of mental health professionals limited, and the provision of full health care coverage by the military being only temporary, growing mental health care needs in rural areas are anticipated. To further compound the problem, some conditions such as posttraumatic stress disorder may not be known for months or years after the individual returns from the war. Despite the challenges presented by the special populations described above and other mental health concerns, all of Iowa has many fundamental common strengths. For example, rural people in general are generous and willing to go out of their way to help their neighbors, noted Arnold. In addition, there are rural people with an entrepreneurial spirit who have a realistic vision of hope for new business ventures and for specialty farming. Communication systems such as the Internet and the Iowa Communication Network can link communities throughout the state for meetings and classes. The challenges and strengths are not the same in every Iowa community, said Arnold. The culture of the residents, the history of the community, and the geography of the area are some of the factors that need to be taken into consideration. Each community is unique and addresses mental health needs in many ways. In some rural communities, churches have provided parish nurses, health ministers, or trained volunteers to fill the gaps in mental health support. By visiting congregants and parishioners going through major events like birth, death, marriage, and illness, church representatives are in a good position to intervene with support or referral to needed services and to initiate health and mental health prevention programs. Another example is the many groups of

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary concerned Iowans working to bring the Latino and the local residents together through leadership, church, and community activities. Nevertheless, more can be done, asserted Arnold. At a recent focus group of the Iowa Rural Health Association, it was suggested that as a first step in looking at solutions, an assessment be made of the help needs of each community or region. Knowledge of the specific needs, the existing infrastructure, and the strengths of a community or region would allow meaningful, workable, and sustainable solutions to surface. Deriving from theories such as those found in Gladwell’s The Tipping Point, planning and strategizing are creative and dynamic processes that make an art—so to speak—of bringing innovative changes to improve mental health care access, treatment, and social response (Gladwell, 2002). From a holistic, creative perspective, this process should not place limits on who takes part. All sectors, including those at the fringes as well as the usual partners and collaborators, must be brought together to create new perspectives and possibilities. Mental health concerns in rural Iowa and rural America are serious but not hopeless. Issues must continue to be studied and researched. Service providers and the community must continue to learn and remain open-minded as they work toward sustainable solutions, concluded Arnold.

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