State of the Rural
Health and
Disability Science
Overview
• A Story
• Rural disability and
health issues
• Health promotion
• Expanded the
purview of our work
Sanders County
• Family of 3 adults
– Power wheelchair user
– Sibling with significant
developmental
disability
– Adult with mental
illness
• Living Independently
• Few needs for support
Rural Health
• Managing funding loss
• Medicare policy
• Attracting qualified
personnel
• Maintaining Hospitals
Clark Fork Valley Community Hospital
Sanders County, Montana
Disability and Rural Health
• People with disabilities face all of the same
generic rural health challenges
• Additional Challenges
– Lack of specialists
– Lack of accessible medical diagnostic technology
– Transportation for services
• “Narrower margin of health” (Pope & Tarlov, 1991)
Health Promotion
• Health promotion can
help address the
narrower margin of
health
• Health Psychology and
Behavioral Medicine
• 2000-2010 Decade of
Behavior
The Role of the Environment
• Individual vs. Environment
• Disability results from the
interaction of person and
environmental factors.
• International Classification
of Function, Disability and
Health (WHO, 2001)
Living Well with a Disability
• Living Well Editions 1 - 3
– Original pilot – 1990
– Randomized trial 1998
• Training program 2000
• Fourth Edition 2010
– Peer support and selfadvocacy
• Community Activated
Living Well
• Participatory Curriculum
Development
Current RTC Health Projects
• Peer Support for
Mental Health
Symptoms
• Consumer Activated
Self-Management
• Participatory
Curriculum
Development
Policy Impacts
• New Freedom Initiative named
Living Well as a national program
of significance to be emulated.
• National Center on Birth Defects
and Developmental Disabilities
names Living Well as an
evidence-based practice
• Aging and Disability Resource
Centers include Living Well
• Montana Medicaid recently
included health promotion as a
reimbursable services
Community-Level Interventions
• National trends toward
community interventions
• Our experience and
observations
• The challenge of
community level
interventions
Vincent Francisco
Dr. Vincent Francisco is the Director of Graduate
Study in the Department of Public Health
Education at the University of North Carolina at
Greensboro
Rural Health and Disability: Potential
Contributions from Public Health
Vincent T Francisco and Craig Ravesloot
Presentation for the State of the Science: Toward a New
Paradigm for Rural America Conference, 20 April 2012.
Intro and Background
• Rural people are less healthy than urban
people (Institute of Medicine, 2005)
• Rural environments have fewer healthcare
resources to address health problems and to
promote health of rural populations
• The cause of this disparity goes well beyond
access to healthcare, the focus of most rural
health researchers and advocates
What Public Health Brings to the Table
• Mission of Public Health – “Assuring the
conditions under which health can occur”
• Focus on access to care and on primary
prevention
• Potentially helpful data focusing on population
outcomes, rather than individual deficits
• Value of democratic inclusiveness
• Focus on improvement of broader environmental
and social conditions
The Ecology of Rural Health
Several theoretical approaches offer some
helpful framing, especially:
• Theories of human development
• Theories of behavioral influences
• Theories of systems and related outcomes
Ecological Model of Rural Health
Structural/Behavioral Model of Development
Facilitative
Optimal
Developmental
Outcome
Personal Variables
• Biology
• History
Non-Facilitative
Environmental Variables
• Social
• Physical
Facilitative
(adapted from Horowitz, 1987)
Socio-ecologic Model of Human Development
(Bronfenbrenner, from McLaren et al., 2005)
Socio-Ecological Model in PH
• Intrapersonal factors—characteristics of the individual such as
knowledge, attitudes, behavior, self concept, skills, etc. This includes
the developmental history of the individual.
• Interpersonal processes and primary groups—formal and informal
social network and social support systems including the family, work
group, and friendship networks.
• Institutional factors—social institutions with organizational
characteristics. And formal (and informal) rules and regulations for
operation.
• Community factors—relationships among organizations, institutions.
And informal networks within defined boundaries.
• Public policy—local, state, and national laws and policies.
(from McLeroy et al., 1988)
BEM Diagram of Two Hierarchical Systems that Combined Help Explain Both Individual and Cultural Practices
Social/Cultural Level
Internal Influences
External Influences
Nationality
Culture Specific
Community Level
Policies
Laws
Media
Local Level
Clinical Services
Built and Social Environment
Individual Level
Normative Group
Physical
Context
Consequences
Behavior
Earlier Time
Learning History
Physiology
Anatomy
Genome
Later Time
Theory of Triadic Influence
Personal
Stream
Levels of
Causation
Biological/Nature
Ultimate
Underlying
Causes
Biology/Personality
Social/Pers
onal Nexus
Distal
Predisposing
Influences
Evaluations
and
Expectations
Affect and
Cognitions
Proximal
Immediate
Predictors
Decisions
Experiences
Environmental
Stream
Social
Stream
Nurture/Cultural
Social Situation
Cultural Environment
Sense of
Self/Control
Social
Competence
Interpersonal
Bonding
Others’
Behs and
Atts
Interactions
w/ Soc Inst’s
Information/
Opportunities
Self
Determination
Skills: Social +
General
Motivation to
Comply
Perceived
Norms
Values/Eval
uations
Knowledge/E
xpectancies
Self-Efficacy, Behavioral
Control
Social Normative Beliefs
Attitudes Toward the
Behavior
Decisions/Intentions
Trial Behaviors and Experiences
Behavior
Related Behaviors
Synergy of Efforts and Syndemics
• Syndemics is the interaction of multiple
epidemics
• Can be behavioral problems, not just
epidemiological problems
• Offers an approach to framing the problem
outside of “blaming the victims”
Minimum Boundary for
Syndemic Thinking
Health
Capacity to
Act
Living
Conditions
• Two or more afflictions, interacting synergistically, contributing to
excess burden of disease in a population.
Adapted from a Syndemics presentation by Bobby Milstein, PhD (CDC Office of the Director)
Systems Science
Basic Problem Solving Orientations
Event Oriented View
Goals
Problem
Decision
Results
Situation
Decisions
Systems View
Side
Effects
Goals
Environment
Goals of
Others
Actions of
Others
Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGrawHill, 2000.
Adapted from a Syndemics presentation by Bobby Milstein, PhD (CDC Office of the Director)
Systems Improvement for Health
Outcomes
• Community Engagement in problem definition
and solution development
• Integration of a systems improvement
approach including feedback mechanisms
related to ongoing improvement
• Resulting in a few big systems improvements,
and a lot of smaller ones
Model for Health Promotion and Community Development
(Fawcett et al., 2000)
Community
Context &
Planning
Community
Level
Outcomes
Risk & Major
Behavior
Change
Community
Action &
Intervention
Community
& Systems
Change
7 Factors Related to Success
•
•
•
•
•
•
•
Targeted Vision and Mission
Leadership (charismatic and distributive)
Action Planning
Capacity Building
Paid Staff
Documentation and Feedback
Making Outcome Matter
Rural Environment and Disability
Rural health issues are exacerbated by several
factors, including:
• Lack of mobility and physical access to
services
• Fewer services available due to economic
factors
• Increased negative effects due to
marginalization and lack of communication
and engagement in decision-making
Case Study 1 – North Carolina
• 4 counties in North Carolina as a pilot project
• Focus on the needs of families of children with
special health care needs (defined broadly)
• Input from the families and the broader
community resulted in several hundred potential
systems improvements across the 4 counties
• Most improvements were sought in
transportation, communications, access to
services, availability of services, and availability of
support services for the families and children
Case Study 1 (cont.)
• 3 years of implementation resulted in over 120
systems improvements across the 4 counties
(low of 20 and high of over 60 within individual
counties)
• Many service providers are adding advisory
boards to their agencies that include the families
• Plans are underway to extend the planning and
collective action to sectors not already covered
Case Study 2 – Rural South Carolina
• Adaptation and adoption of “Living Well with
a Disability” program
• Phase 1: meeting with stakeholders
• Phase 2: relationship building
• Phase 3: working group established to adapt
curriculum
• Phase 4: self-assessment of program
effectiveness
Case Study 2 (cont.)
• Program materials were used beyond the initial
program period and commitments made were honored
• One DSB consumer moved into his own apartment and
participated with other DRC staff and clients in the
“Medicaid Matters” rally in Washington, DC, June 2010
• Inclusion and participation of consumers can enhance
individual behavior and system behavior that promotes
health of community members
• Inclusion of DSB clients in the development of the
program structure and materials was a key to the
program’s success
Conclusions
• People with disabilities face substantial challenges to maintaining
health status.
• With fewer economic and other social resources to draw on, they
are at a distinct disadvantage for health behavior change and
healthcare access despite their greater needs for support.
• Behavioral syndemics emerge that put individuals at risk for
secondary conditions that require even greater access to specialty
medical care.
• Novel solutions to these complex health problems that affect all
rural people can emerge through a community systems approach.
• Organizing across public and private health sectors to create
opportunities for community participation including health
promotion holds promise for addressing these substantial problems
and for meeting the needs of people with disabilities.
Conclusions (cont.)
• Individuals are both responsible for their health and highly
influenced by the environment in which they live.
• As long as community participation in rural communities is limited
by physical, economic, and social structures, the health of people
with disabilities will be at risk.
• Community interventions that level the playing field for all
community members will encourage both individual- and
community-level behavior that improves health for all people.
Recommendations
1.
Include disability screening questions and county of residence on all health
related national data collection efforts to allow analysis of health status between
the general population, people with disabilities, and rural people with
disabilities.
2.
Conduct epidemiological research that examines the relationship between rural
residence, community participation, and health outcomes for people with
disabilities.
3.
Train rural healthcare providers to provide Self-Management Support by
networking with community health resources including health promotion and
disease prevention activities.
4.
Conduct demonstration projects of community level health planning that involve
people with disabilities using participatory research methods.
Discussion
Questions?
Comments?