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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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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


  • 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


  • 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


Lifestyle Factors (50%)

Cigarette Smoking

Alcohol & Drug Consumption


Stress/Mental Well-Being

Body Fitness

Environment (20%)

Biological Predisposition (20%)

Health System (10%)


Education, Income (SES)


Social Support

Community Norms, Beliefs, & Expectations

Direct and Contributing Factors to Health


Household in which we grow up, household which we create as adults

Legal and non-legal attachments, mom,dad,kids,grandparents,extended family, guardians

Doherty, William J. (2002). A family-focused approach to health care.

Illness Appraisal

  • Disease is not merely a biological phenomenon

    • Disease: the sickness/diagnosis itself, bodily processes

    • Illness: the manifestation of disease in and through the individual experience of disease

Health Status

  • 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%)


Southeast Asian refugees

  • poorer health status

  • accepting perception of well-being

  • beliefs about cause of disease

  • beliefs lead to type of healer

Health Promotion and Risk Reduction

  • 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

  • Food shopping limited, healthy foods expensive

  • No health clubs/indoor shopping malls for walking

  • Social life around taverns

    • Alcohol and smoking culture

  • Liquor stores

  • Good information (often confusing messages, internet-based)

Vulnerability and Disease Onset

  • Social support in the family

    • Social ties

    • Stress in family life

Acute Response

  • The immediate aftermath of illness for the family

Adaptation to Illness and Recovery

  • The family as the setting for care of the recovering or chronically ill member.


  • Delivery system: Differently trained health care providers

    • Teaching so providers can assess the influence of family factors on health and thereby

      • 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

    • Ability to pay/be insured

      • Coverage of all family members

    • Availability of providers

Geographic: Supply of ProvidersHealth Care Personnel

  • 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.


Geographic: Supply of ProvidersHealth Care Facilities

  • Rural hospitals

    • 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


Community Activation of Family Health Care: An emerging model

  • Patients and families as partners with professionals

    • Families as producers of health promotion, not just consumers of health care

  • Learning, coping, and healing occur best within communities

    • Identify and activate potential communities

    • Community asset building perspective

Key Findings NACRHHS Report

  • 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

  • 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

  • Higher percentage un- and under-insured for both physical and mental health

  • Medicare rules set standard.

    • Higher copays

    • Only certain professionals reimbursed (not marriage and family therapists)

    • Rural areas have less reimbursable providers to work under

      • Higher copays + less choice + cost sensitive consumers => less access

Behavioral health (BH) and primary care in rural settings: Strategies

  • 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

  • Lack of fluoridated community water supplies

  • Older populations (lifetime of risks, old habits)

  • Increased poverty

    • Less food choice (soda bottle babies)

  • Limited access to oral health care

Rural oral health status

  • Untreated dental caries

    • 31.7% rural, 25.2% urban

  • Lost all teeth

    • 16.3% rural, 8.8% urban (45-64 yr olds)

    • 37% rural, 27% urban (65+)

Access to Oral Health Care

  • Factors limiting access

    • Geographic isolation/lack of adequate transportation

    • Lack of dentists participating in publicly financed programs (~16% nationwide)

      • 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

  • 40% of all older adults report good health

    • Rural older adults report fair to poor health 1½ more than urban older adults

  • Continuous poverty

  • Difficulty accessing transportation

  • Distance to care

  • Lack of knowledge of available services

    • Lack of nearby younger family caretakers

  • Shortage of qualified workers

Rural elderly face significant challenges in accessing needed services

  • 1.6 million older adults in nursing homes

  • Fewer home and community based services makes nursing home use greater in rural

    • 66.7/1000 beds rural

    • 51.9/1000 beds urban

  • Medicaid 10.1% rural, 8.2% urban

Emerging Issues

  • Obesity and wellness

    • Higher rates of chronic disease and limitations on activities of daily living

    • Higher rates of obesity

      • Regular physical activity reduces risk yet inactive leisure time more common among rural residents.

  • Strategies

    • Steps to a Healthier US community grant program (CDC) for diabetes, obesity and asthma prevention

      • Targets prevention efforts: physical inactivity, poor nutrition, tobacco use

      • $13.7 million, $4.4 to small cities and rural communities

        • 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.

  • Access to specialized services (terminal illness)

    • Travel far for diagnosis and treatment

    • Lack of hospice care

  • Health system changes

    • Vulnerability of rural providers to rapid increase in insurance plans that intend to have consumers avoid providers with higher prices

      • Consumers may travel greater distances, further jeopardizing infrastructure of providers for those who cannot travel

  • Families need to be supported in their roles as creators/maintainers of health

    • Knowledge

      • What works, what doesn’t

    • Resources

      • Income

      • Insurance

      • Formal support (health care system)


  • 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.

  • Rural Health Policy Institute, U of Nebraska, http://www.rupri.org/HealthPolicy/

  • http://www.rupri.org/ruralHealth/presentations/mueller111202.pdf

  • http://www.ers.usda.gov/emphases/rural/gallery/

  • Trends in the Health of Americans Chartbook:


References: cont’d.


  • Map book

  • http://factfinder.census.gov/servlet/BasicFactsServlet

  • 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.

    • 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.

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