Putting the Family Perspective
into Rural Health Care
Farm Foundation
National Public Policy Education Conference
Sept 20, 2004
Roberta Riportella, PhD
University of Wisconsin-Madison
University of Wisconsin Extension
Objectives
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To understand a family perspective on
creating health for families
To consider how rural families may be
uniquely affected by changing
demographics and health policy
To consider how a family perspective
might lead to different solutions for
creating health
Methods
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Consider what we know about creating
health
Consider who rural families are
Put those rural families into a model
explaining families’ role in health
Consider what kind of system is in place
to address risks and poor health
outcomes for rural families
Direct and Contributing Factors to
Health
Direct
Contributing
 Lifestyle Factors (50%)
 Education, Income
Cigarette Smoking
(SES)
Alcohol & Drug Consumption
 Self-Esteem
Nutrition
Stress/Mental Well-Being
 Social Support
Body Fitness
 Community Norms,
 Environment (20%)
Beliefs, &
 Biological Predisposition
Expectations
(20%)
 Health System (10%)
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Family
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Household in which we grow up,
household which we create as adults
Legal and non-legal attachments,
mom,dad,kids,grandparents,extended
family, guardians
Family Health and Illness Cycle
Adaptation
Illness appraisal
FAMILY
Acute response
Health promotion
Vulnerability
Doherty, William J. (2002). A family-focused approach to health care.
Illness Appraisal
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Disease is not merely a biological
phenomenon
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Disease: the sickness/diagnosis itself,
bodily processes
Illness: the manifestation of disease in
and through the individual experience of
disease
Health Status
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Health status of the adult rural
population was more frequently
described as fair/poor. (28% vs. 21%).
Chronic conditions in the adult
population as diagnosed by physicians
were also more prevalent in rural areas.
(47% vs. 39%)
http://www.nal.usda.gov/ric/index.html
Southeast Asian refugees
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poorer health status
accepting perception of well-being
beliefs about cause of disease
beliefs lead to type of healer
Health Promotion and Risk
Reduction
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Socialization extends to the variety of habits,
attitudes, behaviors, actions toward health,
as well as attitudes toward using the formal
health care system
What do we learn?
Who needs to be part of the “treatment?”
Are choices individual/family/societal
responsibilities?
Complications to making positive
choices
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Food shopping limited, healthy foods
expensive
No health clubs/indoor shopping malls for
walking
Social life around taverns
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Alcohol and smoking culture
Liquor stores
Good information (often confusing messages,
internet-based)
Vulnerability and Disease
Onset
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Social support in the family
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Social ties
Stress in family life
Acute Response
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The immediate aftermath of illness for
the family
Adaptation to Illness and
Recovery
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The family as the setting for care of the
recovering or chronically ill member.
Implications
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Delivery system: Differently trained health
care providers
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Teaching so providers can assess the influence of
family factors on health and thereby
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Understand individual as whole person and as member of
larger units of family and social/cultural environment
Treat family members as partners in health care
Financing and organization of health care
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Ability to pay/be insured
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Coverage of all family members
Availability of providers
Geographic: Supply of Providers
Health Care Personnel
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The supply of health care personnel represents one
of the greatest contrasts between rural and urban
areas in the United States.
While the rural population makes up 1/5 U.S. citizens,
only 1/10 physicians practice in rural areas.
Specialists are concentrated in urban areas.
Generalists are far more likely to practice in rural.
One reason is rural physicians earn less money.
http://www.nal.usda.gov/ric/richs/stats.htm#demographics
Geographic: Supply of Providers
Health Care Facilities
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Rural hospitals
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2226/5134 in rural areas
Most fewer than 100 beds, mainly private
nonprofits but also include those owned by
state and local governments and for-profit
hospitals.
Heavily dependent on Medicare
1991-1995 363 rural hospital closures
1999 only 24 closures
http://www.nal.usda.gov/ric/richs/stats.htm#demographics
Community Activation of Family
Health Care: An emerging model
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Patients and families as partners with
professionals
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Families as producers of health promotion,
not just consumers of health care
Learning, coping, and healing occur
best within communities
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Identify and activate potential communities
Community asset building perspective
Key Findings NACRHHS Report
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Benefits to integrating behavioral health
and primary care in rural settings
Access to oral health services in rural
communities very limited
Rural elderly face significant challenges
in accessing needed services
Not necessarily family-centered report
Behavioral health (BH) and primary care in rural
settings
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Primary care practitioners have major responsibilities
for diagnosing and treating common mental illnesses
(depression)
BH services are highly fragmented due to staff
shortages
Separate facilities for mental and physical health care
Autonomous BH and primary care providers practice
with informal referral relationships
Primary care and BH providers do not share joint
responsibility for managing patients
Behavioral health (BH) and primary care
in rural settings: Barriers
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Higher percentage un- and under-insured for
both physical and mental health
Medicare rules set standard.
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Higher copays
Only certain professionals reimbursed (not
marriage and family therapists)
Rural areas have less reimbursable providers to
work under
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Higher copays + less choice + cost sensitive consumers
=> less access
Behavioral health (BH) and primary care
in rural settings: Strategies
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Diagnosis and treatment by a fully integrated
clinical team
Co-location of providers
Dual certification of providers
Unknown efficacy of these approaches
Use of Rural Health Centers (3500)
authorized to provide mental health but few
do (only recover 50% cost; paid less than
FQHC)
Factors limited oral health
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Lack of fluoridated community water
supplies
Older populations (lifetime of risks, old
habits)
Increased poverty
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Less food choice (soda bottle babies)
Limited access to oral health care
Rural oral health status
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Untreated dental caries
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31.7% rural, 25.2% urban
Lost all teeth
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16.3% rural, 8.8% urban (45-64 yr olds)
37% rural, 27% urban (65+)
Access to Oral Health Care
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Factors limiting access
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Geographic isolation/lack of adequate transportation
Lack of dentists participating in publicly financed
programs (~16% nationwide)
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Low public financing (<2/3 prevailing rate)
Population thought to miss appts, not comply with advice
Administrative burden
Uneven distribution of practitioners
Poor coordination between dental and medical care
Lack of dental insurance
Cultural attitudes toward dental care
Professional competition issues
Health challenges for rural older
adults
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40% of all older adults report good health
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Continuous poverty
Difficulty accessing transportation
Distance to care
Lack of knowledge of available services
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Rural older adults report fair to poor health 1½
more than urban older adults
Lack of nearby younger family caretakers
Shortage of qualified workers
Rural elderly face significant challenges in
accessing needed services
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1.6 million older adults in nursing
homes
Fewer home and community based
services makes nursing home use
greater in rural
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66.7/1000 beds rural
51.9/1000 beds urban
Medicaid 10.1% rural, 8.2% urban
Emerging Issues
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Obesity and wellness
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Higher rates of chronic disease and limitations on activities
of daily living
Higher rates of obesity
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Regular physical activity reduces risk yet inactive leisure time
more common among rural residents.
Strategies
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Steps to a Healthier US community grant program (CDC) for
diabetes, obesity and asthma prevention
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Targets prevention efforts: physical inactivity, poor nutrition,
tobacco use
$13.7 million, $4.4 to small cities and rural communities
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At-risk populations (ethnic, low-income, disabled, youth, senior
citizens, uninsured, underinsured=rural)
Small city/rural communities component (Washington, NY, Arizona,
Colorado)
Emerging Issues: cont’d.
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Access to specialized services (terminal
illness)
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Travel far for diagnosis and treatment
Lack of hospice care
Health system changes
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Vulnerability of rural providers to rapid increase in
insurance plans that intend to have consumers
avoid providers with higher prices
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Consumers may travel greater distances, further
jeopardizing infrastructure of providers for those who
cannot travel
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Families need to be supported in their
roles as creators/maintainers of health
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Knowledge
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What works, what doesn’t
Resources
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Income
Insurance
Formal support (health care system)
References
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Doherty, William J. (2002). A family-focused
approach to health care. In K.
Bogenschneider (ed). Taking family policy
seriously: How policymaking affects families
and how professional can affect policymaking.
Mahway, NJ: Lawrence Erlbaum Associates.
The 2004 Report to the Secretary: Rural
Health and Human Service Issues. The
National Advisory Committee on Rural Health
and Human Services.
ftp://ftp.hrsa.gov/ruralhealth/NAC04web.pdf
References: cont’d.
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Rural Health Policy Institute, U of Nebraska,
http://www.rupri.org/HealthPolicy/
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http://www.rupri.org/ruralHealth/presentations/m
ueller111202.pdf
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http://www.ers.usda.gov/emphases/rural/gallery/
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Trends in the Health of Americans Chartbook:
http://www.cdc.gov/nchs/products/pubs/pubd/hus/metro.
htm
References: cont’d.
http://www.shepscenter.unc.edu/research_prog
rams/Rural_Program/mapbook2003/totalpopu
lation.pdf
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Map book
http://factfinder.census.gov/servlet/BasicFacts
Servlet
Geographic Comparison Table Census 2000
http://factfinder.census.gov/servlet/GCTTable
?_bm=y&-geo_id=01000US&_box_head_nbr=GCT-P1&ds_name=DEC_2000_SF1_U&-_lang=en&format=US-1&-_sse=on
References: cont’d.
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Uba, Laura. Cultural barriers to health
care for Southeast Asian Refugees.
Public Health Reports, 107, 5, Sept-Oct
1992: 544-548.
Fadiman, Anne. The Spirit Catches You
and You Fall Down. New York, The
Noonday Press, 1997.