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Leveraging Assets to Improve Health and Equity in Rural Communities
- 1. 1 Leveraging Assets to Improve Health and Equity in Rural Communities
- 3. Source: Singh and Siahpush, Widening Rural-Urban Disparities in Life Expectancy, U.S., 1969-2009. American Journal of Preventive Medicine, 2014; 46(2):e19-e29.
- 4. 4 All-Cause Mortality: US vs. Appalachia ‡Rates are presented as deaths per 100,000 population. Rates are age adjusted. *In all years except 1999, the Appalachian rate is significantly different from the non- Appalachian U.S. rate, p ≤ 0.05 Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html Diseases of despair annual mortality rates, ages 15-64, by region (1999-2015)‡* All-cause annual mortality rates, ages 15-64, by region (1999-2015)‡* ‡Rates are presented as deaths per 100,000 population. Rates are age adjusted. *For all years, the Appalachian rates is significantly different from the non- Appalachian U.S. rate, p ≤ 0.05 Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html
- 6. 6 Overdose Deaths: Appalachia ‡Rates are presented as deaths per 100,000 population. Rates are age adjusted. *Appalachian rates are significantly different from the non-Appalachian U.S. rate for the same age group, p ≤ 0.05 Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html Overdose mortality rates for males, ages 15-64, by age group and region (2015)‡ Overdose mortality rates for females, ages 15- 64, by age group and region (2015)‡* ‡Rates are presented as deaths per 100,000 population. Rates are age adjusted. *For all age groups, Appalachian rates is significantly different from the non- Appalachian U.S. rate, p ≤ 0.05 Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html
- 7. 7 The social determinants can be classified into five domains: 1) Economic stability • Poverty, employment, food security, housing stability 2) Education • High school graduation, enrollment in higher education, language and literacy, early childhood education and development 3) Social and community context • Social cohesion, civic participation, perceptions of discrimination and equity, incarceration/institutionalization 4) Health and health care • Access to health care, access to primary care, health literacy 5) Neighborhood and built environment • Access to healthy foods, quality of housing, crime and violence, environmental conditions Social Determinants of Health Healthy People 2020 Framework. http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health
- 8. 8 Social Determinants of Health Rural residents tend to be poorer than urban residents • Average median household income is $42,628 for rural counties ($52,204 for urban counties) (2013) • The average percentage of children living (ages 0-17) living in poverty is 26% in rural counties (21% urban) (2013) Source: http://www.ers.usda.gov/data-products/state-fact-sheets/state-data.aspx#.VFpOS_nF91Y
- 9. 9 Social Determinants of Health Rural residents’ educational attainment (2009-2013) - Averaged across counties 16.5% have < high school education (14.7% urban) 36.3% have only a high school diploma (31.9% urban) 17.4% have a Bachelor’s degree or higher (24% urban) Source: http://www.ers.usda.gov/data-products/state-fact-sheets/state-data.aspx#.VFpOS_nF91Y
- 10. 10 Examination of Trends in Rural and Urban Health: Establishing a Baseline for Health Reform CDC published Health United States, 2001 With Urban and Rural Health Chartbook No urban/rural data update since 2001 Purpose of this study: Update of rural health status ten years later to understand trends Provide baseline of rural/urban differences in health status and access to care prior to ACA implementation
- 11. 11 Methods Replicated analyses conducted in 2001 using most recent data available (2006-2011) Used same data source, when possible: National Vital Statistics System Area Resource File (HRSA) U.S. Census Bureau National Health Interview Survey (NCHS) National Hospital Discharge Survey (NCHS) National Survey on Drug Use and Health (SAMHSA) Treatment Episode Data Set (SAMHSA) Applied same geographic definitions, although classifications may have changed since 2001: Metropolitan Counties: large central, large fringe, small Nonmetropolitan Counties: with a city ≥ 10,000 population, without a city ≥ 10,000 population
- 12. 12 Mortality: Children and Young Adults Death rates for all causes among persons 1–24 years of age by rurality
- 13. 13 Mortality: Working-Age Adults Death rates for all causes among persons 25-64 years of age by rurality
- 14. 14 Mortality: Seniors Death rates for all causes among persons 65 years of age and over by rurality
- 15. 15 Mortality: Chronic Obstructive Pulmonary Diseases Death rates for chronic obstructive pulmonary diseases among persons 20 years of age and over by rurality
- 16. 16 Mortality: Suicide Suicide rates among persons 15 years of age and over by rurality
- 17. 17 Risk Factors: Adolescent Smoking Cigarette smoking in the past month among adolescents 12-17 years of age by rurality
- 18. 18 Risk Factors: Adult Smoking Cigarette smoking among persons 18 years of age and older by rurality
- 19. 19 Risk Factors: Obesity Obesity among persons 18 years of age and older by rurality
- 20. 20 Regional Mortality Study Purpose: To examine the impact of rurality on mortality and to explore the regional differences in the primary and underlying causes of death.
- 21. 21 HHS Regions
- 22. Figure 46 Regional Differences in Mortality: Males; 25-64; Region 6 (AR, LA, NM, OK, TX)
- 23. Regional Differences in Mortality: Females; 25-64; Delta Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Multiple Cause of Death.
- 24. Regional Differences in Mortality: Males; 25-64; Appalachia Michael Meit, Co-Director of the Walsh Center Meit-Michael@norc.org 301-634-9324 Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Multiple Cause of Death.
- 25. Health is an economic and community development issue in Rural America 25 Bottom line….
- 26. Exploring Strategies to Improve Health and Equity in Rural Communities
- 27. • Conduct formative research to identify strengths, assets, and strategies that will accelerate and improve health and well-being in rural communities. • Identify factors and cross-sector partners that can influence health and well-being within rural communities, including why barriers have not been overcome in the past. • Identify opportunities for action and a set of recommendations for diverse rural stakeholders and funders. 27 Project Purpose
- 28. 28 RWJF Culture of Health Action Framework
- 29. Needs and Deficits Assets and Capacities Opportunities for Action 29 A Shift of Focus
- 31. 31 Cross-Sector Strategies Sample of Sectors Represented • Economic Development • Education • Media • Aging • Healthcare • Mental Health • Transportation • Housing • Public Health • Cooperative Extension • Environmental Health/Utilities • Youth Development • Physical Activity • Local Philanthropy • Food Systems • Churches • Community Development • Veterans • Early Childhood
- 33. Rural communities are hubs of innovation – a lack of financial resources can help foster creative solutions to local challenges – our problem is knowing where to find this innovation. 33 Key takeaway from regional meetings…
- 34. • Roles of RDO’s in strengthening rural communities: • conveners, especially in resource scarce areas • resource connectors, • backbone organizations, • capacity builders, • project managers, • technical assistance providers to help different sectors work together • Strategies that work tend to center around building infrastructure and addressing system-level priorities as opposed to specific programs and interventions 34 Input from the Planning and Development Sector
- 35. • Recommendations for the Planning and Development Sector • More time and resources during planning for building shared understanding and community buy-in on social issues • Recommendations for the Health Sector • Once healthcare organizations embrace more population health priorities, they can partner with RDO’s to address upstream issues and collaborate with other sectors 35 Input from the Planning and Development Sector
- 36. • Recommendations for national funders • Foundations can play crucial role by funding work that can’t be funded by government • Allow for innovations within regions and support local ideas and solutions • Encourage national associations in different sectors to figure out how they can support the work of other sectors • Find ways to measure success of community work that captures the impact of social, cultural, and intellectual assets on health and wellbeing 36 Input from the Planning and Development Sector
- 37. Preliminary Recommendations and Opportunities for Action
- 38. • Continued Foundation Learning • Strengthening Community Implementation Capacity • Identifying and Growing Rural Leaders • Community Development/Economic Development • Building the Rural Evidence Base • Fostering Cross-Sector Collaboration • Enhancing Community-Level Evaluation and Measurement • Co-Funding and Utilizing Regional/Local Intermediaries • Finding and Replicating “Rural-Centric” Health Innovation • Rural Specific Communications and Messaging • Fostering Learning Across Communities Preliminary Set of Recommendations
- 39. • What is missing? Are there additional recommendations that could be actionable for a large national funder? • Can you offer specific guidance for how recommendations may be implemented? What kinds of support could a large national funder provide? • Do you have real world examples where any of these strategies have worked? 39 Discussion
- 41. Michael Meit, Co-Director NORC Walsh Center for Rural Health Analysis 4350 East West Hwy, Suite 800 Bethesda, MD 20814 301-634-9324 Meit-Michael@norc.org Thank you!
Notas del editor
- Slides 1-4 are based on data in Gopal Singh’s article. It shows a widening gap between Life Expectancy in urban and rural areas. (Metro vs. non-metro counties) In 1969-71 the gap was only 0.4 years. “By 2005–2009, the life expectancy difference had increased to 2.0 years (78.8 vs 76.8 years).”
- Graph on left: All-cause mortality rate in the non-Appalachian U.S. declined steadily between 1999 and 2014, before increasing between 2014 and 2015. Between 2014 and 2015, the non-Appalachian U.S. rate increased by 1.4 percent, and the Appalachian rate increased by 3.1 percent. Graph on right: The disparity in mortality from the diseases of despair has been growing since 1999. In 1999, non-Appalachian U.S. was slightly higher than Appalachia, but by 2015, the mortality rate in Appalachia was 37 percent higher than the rest of the nation.
- Note the impact on the 25 – 54 age range – Prime working years are being impacted most. While the overall burden is lower among women, the disparity between Appalachia and the non-Appalachian U.S. was greater.
- http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health
- Disparities are greater in the Appalachian region
- Average high school attainment for adults age 25 and older for the U.S. across all counties or central Appalachian counties – data from the 2009-2013 American Community Surveys
- Death rates for children and young adults (ages 1–24 years) are much lower than those for older persons. However, over 60 percent of the deaths in this young group are due to injuries, both unintentional and intentional, and therefore largely preventable (1). The proportion of deaths due to injury increases with age from 41 percent for children 1–4 years old to 73 percent for young persons 15–24 years old (2,3). Nationally, the age-adjusted death rate for children and young adults increases steadily from fringe counties of large metro areas to the most rural counties (48 to 76 per 100,000 population for males, 22 to 38 per 100,000 for females in 2008-2010). The mortality differential between fringe counties and the most rural counties in 1996–98 ranged from about 37 percent for males in the Midwest to 107 percent for males in the West. Death rates for both males and females in central counties of large metro areas are lower than rates in the most rural counties for all regions.
- Deaths among persons ages 25–64 years accounted for 24 percent of all deaths in the United States in 2010 (1). The three leading causes of death for working-age adults are cancer, heart disease, and unintentional injuries, with lung cancer the leading cause of cancer mortality (2,3). Nationwide age-adjusted death rates for working-age adults are lowest in fringe counties of large metro areas (356 per 100,000 population for men and 213 per 100,000 for women in 2008-2010). For men, death rates in central counties and the most rural counties were 18 percent and 44 percent, respectively, higher than in fringe counties. For women, the excess in central counties and the most rural counties was 14 percent and 47 percent respectively. In all regions the lowest death rates for working-age adults occur in the fringe counties of large metro areas. In the Northeast and Midwest, the death rates are highest in central counties (28–37 percent higher than in fringe counties). In the South death rates are highest in nonmetro counties (34–60 percent higher than in fringe counties).
- Almost three-quarters of all deaths in the United States occur among persons age 65 and over (1). The top five causes of death for elderly Americans are heart disease, cancer, chronic obstructive pulmonary disease, stroke, and Alzheimer’s Disease (2). Provision of appropriate and timely health services can help seniors prevent, treat, and manage chronic illnesses, thus enhancing quality of life and preventing premature death. The national age-adjusted death rate for elderly men is lowest in large metro (central and fringe) counties and highest in nonmetro counties (about 4,900 compared with about 5,600 per 100,000 in 2008-2010). For elderly women the rate is lowest in central counties of large metro areas and highest in nonmetro counties (3,744 compared with over 4,200 per 100,000). The urban-rural upward gradient for seniors (13 percent for men and 14 percent for women) is less steep than for younger persons, but it involves many more deaths because deaths rates for seniors are much higher than for younger persons. Urbanization patterns of mortality among seniors are similar for men and women within regions but vary across regions. In all regions except the Midwest, mortality among seniors is lowest in large metro (central and fringe) counties and highest in nonmetro counties. In the Midwest mortality is lower in nonmetro counties than in large metro counties for women.
- Chronic obstructive pulmonary diseases and allied conditions (COPD) are diseases characterized by obstruction of airflow (such as chronic bronchitis, emphysema, and asthma). COPD is the third leading cause of death in the United States, claiming over 138,000 lives in 2010 (1). Cigarette smoking is the most important risk factor for COPD. Occupational exposure to airborne pollutants such as solvents and dusts contribute to COPD (2). Nationwide, the age-adjusted COPD death rate for men 20 years and over increases as urbanization decreases (from 64 per 100,000 population in central counties of large metro areas in 2008-2010 to 101 per 100,000 in the most rural counties). A similar pattern holds true for women (from 51 per 100,000 population in central counties to 69-70 in nonmetropolitan counties). Nationwide, the age-adjusted COPD death rate for men 20 years and over increased between 1996-1998 and 2008-2010 in nonmetropolitan counties (from 87 per 100,000 population to 98 per 100,000 population), but decreased in metropolitan counties. In women nationwide, the age-adjusted death rate increased across all levels of rurality. For men the regional patterns follow the national pattern. Men in the Northeast have the largest urban-rural increase in COPD mortality, followed by men in the South. For women COPD death rates show an urban-rural increase only in the South. Non-Hispanic white persons and Puerto Ricans have higher COPD death rates than any other racial and/or ethnic group. Mexican-American adults have the lowest rates (3).
- Suicide is the tenth leading cause of death in the United States and the third leading cause for men ages 15–24 years (Health, United States, 2012, tables 22 and 23). Non-Hispanic white persons followed by persons of American Indian heritage have the highest age-adjusted suicide rates in the United States; Asian, black, and Hispanic persons have rates about one-half those of the other two groups (Health, United States, 2012, table 35). In the United States as a whole, there is a clear urban-rural increase in suicide rates for both sexes. In 2008-2010 age-adjusted suicide rates for males 15 years and over were 21–22 per 100,000 population in the large metro counties (central and fringe) and 33 per 100,000 in the most rural counties. Suicide rates for males 15 years and over are 3-5 times as high as those for females, with the divergence increasing as urbanization decreases. The age adjusted suicide rates for females 15 years and over were 6 per 100,000 population in large metro counties (central and fringe) and 7 per 100,000 in the most rural counties. Among males, the urbanization pattern of suicide within each region follows the national pattern. The steepest urban-rural gradient is in the West. Among females, the only region with a clear urban-rural upward gradient is the West. For both sexes, the suicide rates in the nonmetro counties of the West were higher than those in any other region.
- Smoking is the single most preventable cause of disease and death in the United States (1). Between 1991 and 2011, smoking among high school students decreased from 28 percent to 18 percent (2). This trend is critical to improving the public’s health since over 85 percent of adults who are addicted to tobacco began smoking as adolescents (3). Current cigarette use (smoking 1 or more days in the past month) among adolescents 12–17 years of age differs by urbanization level. In 2010-2011, adolescents living in central counties of large metro areas [A] had the lowest rates of cigarette use (5 percent) and those living in the most rural counties [E] had the highest (11 percent). In all regions, the smoking rate among adolescents was directly related to rurality. Smoking was more common among adolescents living in nonmetro counties [D,E] than among those living in central counties of large metro areas [A]. Across all regions and urbanization levels, the lowest rate of adolescent smoking was found in central counties of large metro areas [A] in the South (5 percent), while the highest rate was seen in the most rural counties of the Midwest [E] (13 percent). In all regions except the West, adolescents residing in the most rural counties [E] were more likely to smoke (11 percent in the South, 12 percent in the Northeast, and 13 percent in the Midwest). In the West, adolescents residing in fringe counties of metro areas [B] were most likely to smoke (9 percent).
- After dramatic declines in cigarette smoking among adults following the first Surgeon General’s Report in 1964 (1), the decline among adults stalled. The percent of adults smoking declined from 42 to 25 percent between 1965 and 1990. By 2011, smoking prevalence decreased to 19 percent (Health, United States, 2012, table 54). Understanding where smoking prevalence remains high may assist in planning population-specific campaigns to reduce smoking. From 2010-2011, adults living in nonmetro counties [D,E] were significantly more likely to smoke than adults in metro counties [A,B,C] nationwide (25 percent of women and 29 percent of men in in nometro counties [D,E] compared to 13 percent of women and 19 percent of men in central counties of large metro areas [A]). Regionally, smoking rates were also highest in nonmetro counties [D+E]. The largest urban-rural disparity in smoking rates was seen in the South, where smoking rates for men rose from 20 percent in fringe counties [B] to 33 percent in nonmetro counties [D+E] and for women rose from 14 percent in central counties (A) to 27 percent in nonmetro counties [D+E]. Across all urbanization levels, smoking rates for men and women were generally lower in the West than in other regions. Since 1997-1998, national adult cigarette smoking rates decreased in all metro counties (by 3-7 percent). In nonmetro counties with a city, smoking rates increased slightly (less than 2 percent). Adult cigarette smoking rates decreased only slightly (less than 2 percent). By region, smoking rates decreased across urbanization levels, except in the South and West, where smoking rates increased slightly in nonmetro counties.
- Obesity—defined as a ratio of body weight to height—has been linked to a variety of serious chronic illnesses, including diabetes, heart disease, cancer, and arthritis. Between 1960 and 2010, the proportion of adults in the United States who are overweight or obese increased from 45 percent to 69 percent (Health, United States, 2011, table 74), making it an increasing public health concern. Self-reported obesity varied by urbanization level and increased with increasing levels of rurality. In 2010-2011, women living in central counties of large metro areas [A] nationwide had the lowest age-adjusted prevalence of obesity (29 percent) while women in the most rural counties the highest [E] (40 percent). The pattern for men was the same as for women; self-reported obesity rates were higher in more rural areas [E]. The lowest rates were seen in central counties of large metro areas [A] (26 percent) while the highest rates were observed in the most rural counties [E] (35 percent). The correlation between self-reported obesity and rurality was also present at the regional level. Among women, obesity prevalence was lowest in fringe counties of large metro areas [B] in each region except in the West, where it was lowest in central counties [A]. Among men, the only difference was observed in the Midwest, where there was little variation in obesity rates across urbanization levels. Across regions, the highest self-reported obesity rate among men was in nonmetro counties [D+E] in the West (36 percent) while, among women, it was in nonmetro counties in the South [D+E] (40 percent). Since 1997-1998, self-reported obesity rates have increased across regions and urbanization levels. The largest increases were seen in nonmetro counties for all regions, with the exception of the Midwest where small metro counties had the greatest increase.
- This is showing the mortality index. The index quantifies the comparison between the mortality rate for a specific HHS region, gender, age, cause to the national mortality rate for that age group, for that specific cause. An index of 100 indicates that there is not difference from the national rate; an index <100 indicates that the specific rate is lower than the national; and >100 indicates that the mortality rate is larger than the national.
- The NORC Walsh Center for Rural Health Analysis has been contracted by the Robert Wood Johnson Foundation (RWJF) to explore opportunities to improve health and equity in rural communities through consideration of rural assets and capacities, priorities, regional culture and history, and partners. By rural health and equity, we are referring to population-level health and the conditions that promote healthy, thriving communities for everyone.
- Adapting an asset-based community development approach by McKnight and Kretzmann, grouped assets, capacities, and mechanisms for improving health and well-being into categories and subcategories: Individual Assets: The knowledge, skills, attributes, abilities, and actions of people Organizational and Associational Assets: The organizational and associational resources in a community which are primarily controlled on a local-level Community Assets: These are assets and resources physically located within a community but are often not controlled locally Cultural Assets: These are factors which operate at a variety of levels and are particular to the culture of the community, including historical context and belief systems 1. Kretzmann, J.P. and McKnight, J.L. Building Communities from the Inside Out: A Path Toward Finding and Mobilizing Community Assets. ACTA Publications, Chicago, IL: 1993. 2. Brighter Futures Together Toolkit, The Sustainable Communities North East Initiative. http://www.brighterfuturestogether.co.uk/wp-content/uploads/2012/02/assets-diagram-2-large.jpg 3. Social Ecological Model. Division of Cancer Prevention and Control, Centers for Disease Control and Prevention. https://www.cdc.gov/cancer/nbccedp/sem.htm
- Conducted a national discussion forum and 24 key informant interviews with national/regional stakeholders to start the conversation around rural assets and strengths, roles of various sectors, and recommendations to improve health.
- US Mexico Border: Deming, New Mexico Delta: Delhi, Louisiana Northeast: Norway, Maine Upper Midwest: Black River Falls, WI
- Through our literature review, key informant interviews, and regional meetings, we identified community development and planning organizations as a key partner in strengthening rural communities and addressing social determinants of health. Since this project specifically aims to work across sectors, we conducted a focus group with regional development organizations (members of NADO) in July to discuss: what opportunities you see to fundamentally improve health and equity in rural communities, and what supports your organizations and NADO may need to further engage in rural health and equity related issues. This focus group discussion is being analyzed along all our other data sources, but we wanted to share back a few findings that may be of interest and relevant to your work. More detail: Strategies that work: Development of trails seemed to help people be more physically active, increase of businesses supporting outdoor physical activity Water and sewer lines to reduce exposure to ground contamination Housing for homeless population
- Recommendation #4: Examples include ripple mapping techniques, changes in perceptions about root causes and social determinants, reduction of stigmatization, changes in social cohesion
- We are iterating these recommendation categories.