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Health Disparities Among Rural Populations: A Systematic Review
by
Allison K. Wood
BS, University of Maine at Farmington, 2010
Thesis Submitted in Partial Fulfillment
of the Requirements for the
Master's Degree in Public Health
Concordia University
August 2017
Abstract
There is a significantly lower number of physicians/ providers care for the number of rural residents in each area, and a higher rate of chronic conditions and diseases. There is a gap between rural and urban communities that is present; and rural residents are found to have both a lower quality of life and lower longevity of life than urbanites. How the health of rural residents is approached by professionals, providers and patients provides insight into the most effective means to avoiding higher instances of disease and death among this population. A total of 12 studies were included- while both qualitative and quantitative in nature; the majority were found to be qualitative.
The studies included were Randomized Control studies, Cohort or Case Control studies. Findings solidified and further confirmed the barriers encountered by rural residents in their quest to become or remain healthy. Rural health disparities impact those of all ages in a rural community. Recommendations due to such contrast between urban and rural community members includes additional research and resources allocated to rural health causes and care. Rural communities face many similar challenges to those in urban areas such as cancer, diabetes, personal injury, limited preventative testing; but the means by which to address health concerns are significantly less than those living in an urban area with more ease of access to care when needed.
Introduction
Problem Statement
‘Rural’ defines several communities throughout the country today. Merriam-Webster (n.d) defines ‘rural’ as “of or relating to the country, country people or life, agriculture”. Though numerous individuals and families call these locations home, the health problems that are present in these areas are unique, and in certain circumstances, more prevalent than those one may find in urban areas (Miles et al., 2011). Rural areas are faced with less availability of care; and less resources for the care that can be accessed. For rural communities; financial resources or assistance are less prevalent; as well as, less physical resources that residents may have readily available. These contribute to a higher prevalence of health concerns, conditions and disease with less care received to treat them (Harris et al., 2016).
There is a reality faced among rural populations that includes a persistent gap in life expectancy between rural and urban communities, with data showing that rural areas experience poorer health on almost every factor and have less healthcare infrastructure to support residents (Hoban, 2017). There are several problems that are found among rural residents that are less prevalent with urban populations. According to the Centers for Disease Control and Prevention(CDC) and study by Downey (2013),rural communities have higher rates of preventable conditions such as obesity, diabetes, cancer, and injury, and higher rates of related high-risk health behaviors such as smoking, physical inactivity, poor diet, and limited use of seatbelts (Downey, 2013). This is not an entirely conclusive listing, as selected conditions and behaviors are specific to one area over another. Overall, residents residing in areas considered rural are often a greater distance from care; have a limited number of providers or care options available, and less means by which to access necessary services.
The purpose of this systematic review wasto focus on access to quality, regular care and the effect it has on overall health status. Those residing in rural areas are at risk for less providers to care for them, higher rates of disease and conditions, isolation in access, awareness and information or education (RHIhub, 2015). Although the focus of this systematic review is rural America; it was important to look to other areas of the world for the purposes of comparing the means of intervention(s) and their impact effectiveness (Stafford et al., 2014).
Rural culture, in and of itself, is unique. Those in rural areas may vary from those who live in urban areas due to their environment, required resiliency and independence (Hrushka, 2009). The community setting in which one lives is a significant aspect of health and overall lifestyle, although individuals may or may not interact with one another on a regular basis (Quansah et al., 2016).
Purpose Statement
The purpose of this systematic review was to examine and identify the connections to be found between community-based prevention programs and/ or early intervention, and changes to the reported or observed health status of rural residents: and what prevented such changes from taking place.
Although there has been research conducted on the impact of health care interventions, aimed at the reduction of chronic disease, this has been without consideration of proximity and quality of care variable. For the purposes of this research the focus remained on geography, more specifically, that of rural areas and their residents (NIH.gov, 2016). The majority of healthcare intervention studies focused on the reduction of chronic diseases or conditions without the consideration of the barriers that are present.
Research Question and Hypotheses
The research question addressed was: Does accessibility influence the health understanding and status of rural residents?
H1: There is an association between access (due to proximity) to regular, quality care and the health status of rural community members.
Potential Significance
In past research; there has been a gap in research that addresses the health concerns that are unique to rural communities. This review aimed to justify the need for further research to find effective programs for primary chronic disease/ condition prevention rather than for the need for tertiary or secondary care to be as prevalent. This systematic review aimed to build upon what research was already conducted throughout the field, and was developed in support of current findings that public health outreach and overall care is lacking; causing disparities among rural residents throughout the country.
Background Literature Review
Theoretical Foundation
This emphasis on empowerment and contextual influences allows for a more holistic conceptualization of health and approaches to promoting health that are anchored in principles of community development and systems change” (Lardon et al., 2011, p. 65) Per Merriam-Webster, Community organization is the “…organized development of community welfare through coordination of public and private agencies (n.d). This theory involves the community and the those caring for them in a collaborative effort to recognize the problem taking place (disparities), planning and then implementing action steps to face the problem and work together to assist in resolving it (dhhs.gov, 2002).
The Community Organization theory acknowledges that whether in an organization or community, there are norms and rules that apply uniquely to such communities (Goodkind, et al., 2011). Thiscould also pertain to health disparities and related research. In any community area, but particularly for those who may be in otherwise isolated areas of low populations, the aspects of the community organization theory can be of key importance. As in the application of this theory in a rural Alaskan community; the use of the community organization theory recognizes that “Health promotion aims to support people in their efforts to increase control over factors that impact health and well-being” (Goodkind, et al., 2011 p. 452).
The Community Organization theory was used in a study to counter the barriers to health that were faced by working class Latinas throughout the U.S (Hsieh et al., 2016). This study occurred to determine what needed to be developed to impede the drastic disparities that were faced by a large amount of the population; especially those who are among working-class minorities. This specific study highlighted the many and differing effects on the health of this population. All aspects of social, occupational, spatial exposures and mental health contribute to the larger picture of health for any individual, especially those who may be additionally susceptible to or vulnerable toward disparities (Hsieh et al., 2016)
With health disparities; especially among rural populations, community is an integral part of social behaviors, norms and established habits. Those in rural areas may vary from those who live in urban areas due to their environment, required resiliency and independence (Hrushka, 2009). The community setting in which one lives is a significant aspect of health and overall lifestyle, although individuals may or may not interact with one another on a regular basis (Quansah et al., 2016). Community members in rural areas rely on one another for several aspects of daily life. By incorporating community and involving those within it, there can be improvement to the response; and further strengthen the community. Use of the Community Organization theory will enhance the norms and rules that may be obvious or remain unspoken, allowing rural residents to address their health in the most appropriate and familiar means for such communities. Use of the Community Organization theory involves and empowers to community to be included in improving their own health status and lessen the disparities encountered.
The Organizational Change theory involvescertain processes and strategies that potentially will increase the chances that healthy policies and programs will be adopted and maintained in formal organizations and settings (dhhs.gov, 2002). Per the business dictionary, such a theory involves the study of organizational designs and structures, relationship of organizations (or communities) with their external environment (2017). It suggests ways in which an organization can cope with rapid change. For the research topic of health disparities and addressing the research question, the awareness message to define the problem of health disparities, the adoption stage for initiation of action, the initiation of action through the adoption stage, before the implementation of change and institutionalization of change will all be prominent aspects of health disparities being addressed and changed for rural residents.
In theory’s application to health disparities; this can provide great insight to possible community level or even policy-level change taking place. Beginning at the ground roots level of a community and building upon the foundation a community has established. Involving the community in care clinics, educational forums and health fairs to reach out and spread information. Once an effective system for sharing and implementing information and education surrounding care has been established, this can be expanded to tentatively include communities at regional, county, state or even country-wide levels.
Key Variables or Concepts
According to National Institute of Health (2016); health disparities refer to differences in the health status of different groups of people. Some groups of people have higher rates of certain diseases, and more deaths and suffering from them, compared to others. These groups may be based on race, ethnicity, immigrant status, disability, sex or gender, sexual orientation, geography, or income.
An improved health status for rural populations remains the ideal outcome and can lead to a positive change for the field of public health servicing rural locations. The outcome of interest would mean that the most prevalent of health disparities:i.e. higher rates of certain diseases and deaths (NIH.gov, 2016) would be minimized or even eliminated to the greatest degree possible. The aspects involved in an improved health status would include health and health behaviors, access to healthcare services and receipt of preventative care. Among those larger disparities, the overall improved health status would bebroken-down into more manageable steps through the process of intervention to address overall fair to poor health status, higher rates of diabetes and obesity (Miles et al., 2011), lack of healthcare coverage or deferring coverage/ care due to associated cost, less compliance with preventative care and necessary screenings (Bennett et al., 2008). This is exacerbated further for those not only marginalized, but also those who may be considered minority populations.
Interventions found to be the most effective are those that are culturally-aware; involving a broad approach to intervene for those at a disadvantage in their health and communicated to reach a significant portion of the population (Kontos, 2011). Additionally, they should be in a language and way in which information can be grasped and retained (Kontos, 2011). Rural culture, in and of itself, is unique. Those in rural areas may vary from those who live in urban areas due to their environment, required resiliency and more.Therefore, the way that health information is shared should be adjusted accordingly to acclimate to the community’s needs (Hrushka, 2009). The community in which one lives is a significant aspect of health and overall lifestyle, although individuals may or may not interact with one another on a regular basis (Quansah et al., 2016).
Each facet of the studies included barriers experienced by rural people on a regular basis. The increasing importance of telehealth services and the impact that challenges providers and the populations encountered throughout rural locations was evident in the studies of Singh, et al., 2010) and (Brems, et al., 2006) and the efforts of all involved to improve the health status and discouraging statistics associated with rural community members. In the studies featuring farmers market use (Freedman, et al., 2016) and the studies on the implications and influence of and on rural culture; one can determine the impact that the isolation or rural living can lead to: high levels of risk factors and worse reported health status (Hartley, 2004) and (Hruschka, 2009 ) these risks are also not limited to adult who call rural areas home; those susceptible or vulnerable to feeling the effects include youth in and out of school settings ( Berlin, et al., 2013) (Villalba, 2007) The remaining studies indicated the variance that can often occur between those rural residents living in one particular area as opposed to another; and the information able to obtain due to educational attainment levels that may or may not have been achieved in their lifetimes; yet again, due in part; to access; and or situation/ circumstance.
Among the selected studies; specifically, those pertaining to diabetes awareness and education. The way that information was presented varied for rural patients based on patient response and reaction (Brems, et al., 2006; Danaei, et al., 2010). If and when information is not shared by means rural individuals can grasp and apply, there is less potential for those individuals to put effort, initiative and/ or complete commitment toward improving their health condition or health status in a more inclusive way (Brems, et al., 2006; Danaei, et al., 2010).
The first step of intervention to address health disparities among those living in rural America is prevention. Through education, and information-sharing, much can be learned about health disparities, conditions and diseases that are most prevalent; the lack of healthcare coverage or deferring coverage/ care due to associated cost, low compliance rates with preventative care and necessary screenings overall health status, and rates of diabetes and obesity (Bennett et al., 2008; Miles et al., 2011).
Allowing those in rural areas to remain involved and empowered in their health will be integral in maintaining their interest and investment beyond the initial prevention stage (Beaudoin, et al., 2014).in preventing the progression of health conditions such as diabetes, unintentional injury, heart conditions, and obesity, and they are most at risk for surrounding health behaviors, care and prevention measures (Beaudoin, et al., 2014). Rural community members becoming engaged is integral in their continued involvement in improving the health status’ of themselves and others in their surrounding communities (Wholey, et al., 2009).
To further plan and implement interventions that will truly make a difference in health disparities, the interactions of all elements of health that can be influenced and affected by these disparities were investigated further. Health is an increasingly involved element of day-to-day life; it involves far more than one may anticipate. Population health goes beyond health in what was previously known as health in the ‘traditional’ or what may be considered the typical sense (Hartley, 2004). Population health is known as an approach to health in consideration of a population overall, and the aspects and actions that can take place- in the general sense- to improve the health of much of the population or group (phac-aspc.gc.ca, 2012).
The social determinants of health- as defined by Healthy People 2020 include five areas: economic stability, education, social and community context, health and health care and the neighborhood and built environment (healthypeople.gov, 2017). The World Health Organization (WHO) identifies social determinants of health (SDH) as the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems (who.int, 2017).