Managing Food Insecurity in Rural Areas

In 2023, almost 14% of U. S. households had food insecurity. In rural areas, thisprevalence is even higher at 15.4% (Rabbitt et al., 2023). We also know that healthy food is difficult to obtain in low-income households, especially in rural communities. Ultimately, fewer monies and geographic access to healthy foods leads to lower dietary quality among those in rural households with low-incomes (Ohri-Vachaspati et al., 2019). These food struggles relate to many factors including the inability to buy nutritious food (e.g., high-quality protein, fruits, and vegetables) because of either unemployment, low-income or seasonal jobs, high food prices, needing to use funds for essential household and medical needs, selecting poor food choices because of tiredness from working long hours, and because grocery stores with wholesome foods often are many miles away from their home (Byker Shanks et al., 2022).

These families use many support systems to obtain food, such as local food pantries, food assistance programs, school meals, and borrowing either money or food from family and friends. Rural residents also take advantage of gardening, hunting, fishing, and canning food for later use by their families. They also use money-saving strategies to buy more food by visiting stores who offer coupons or sales, purchasing generic brands, buying bulk items or dented /damaged packages and cans, and comparing grocery store unit prices for specific items. They also serve simple meals with fewer food options (Byker Shanks et al., 2022).

Despite these various strategies, many rural households with low incomes still struggle to feed their family desirable and nutritious food, which requires a multi-level approach to this problem. Nurse practitioners, nutritionists, social workers, other health providers along with community stakeholders are key in developing creative strategies to help these families secure more nutritious food options for themselves and their families. Health providers can share information about federal nutrition programs and do referrals to departments of human services during wellness examinations. Free educational programs on nutrition are important. Community stakeholders can advocate for policies to address food insecurity. Community efforts to emphasize the value of food programs for children and their parents and the elderly are a high priority, including community food trucks, food shelters/pantries, and emergency food programs. Community connections and events can provide opportunities to enhance social networks, with shared transportation to food stores, farmer’s markets, and neighborhood sponsored community gardens, with childcare/supervision. These social events also provide opportunities to make friends and share ideas for nutritious meals and strategies to prepare time-saving meal plans (American Hospital Association, 2024; Schuler et al., 2024). Together, these group efforts can improve rural food insecurity.

References

American Hospital Association. (2024). Hospitals and food insecurity. https://trustees.aha.org/articles/1299-hospitals-and-foodinsecurity#:~:text=Hospitals%20and%20health%20care%20providers,dietitians%20and%20nutritionists%20for%20counseling

Byker Shanks, C., Andress, L., Hardison-Moody, A., Jilcott Pitts, S., Patton-Lopez, M., Prewitt, T. E., Dupuis, V., Wong, K., Kirk-Epstein, M., Engelhard, E., Hake, M., Osborne, I., Hoff, C., & Haynes-Maslow, L. (2022). Food insecurity in the rural United States: An examination of struggles and coping mechanisms to feed a family among households with a low-income. Nutrients, 14(24), 5250. https://doi.org/10.3390/nu14245250

Ohri-Vachaspati, P., DeWeese, R. S., Acciai, F., DeLia, D., Tulloch, D., Tong, D., Lorts, C., & Yedidia, M.J. (2019). Healthy food access in low-income high-minority communities: A longitudinal assessment-2009–2017. International Journal of Environmental Research in Public Health. 16, 2354. https://doi.org/10.3390/ijerph16132354

Rabbitt, M. P., Reed-Jones, Hales, L. J., & Burke, M. P. (2023, September). Household food security in the United States in 2023. USDA, Economic Research Service, ERR-337. https://www.ers.usda.gov/webdocs/publications/109896/err-337.pdf

Schuler, B. R., Shipe, S. L., O'Reilly, N., Uhl, A., Vazquez, C. E., Tripicchio, G. L., & Hernandez, D. C. (2024). Balancing nutrition and budgets: Socio-ecological impacts on nutritional environments of families with low incomes. Appetite, 203, 107706. https://doi.org/10.1016/j.appet.2024.107706

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Individuals who live in rural areas have significantly higher rates of COPD and COPD-related hospitalizations and deaths than those who live in urban areas. In fact, those who experience COPD and reside in rural counties (8.2%) are almost double the number of those individuals who live in urban areas (4.7%). States with higher quartiles for COPD are Alabama, Arkansas, Indiana, Kentucky, Mississippi, Tennessee, and West Virginia, four of which have higher percentages of rural residents (Croft et al., 2015). These rural individuals are more likely to experience negative social determinants of health, such as lower incomes, education, chronic illness and comorbidities, and disability, with more individuals commonly foregoing medical care due to having inadequate health insurance and monies (Gaffney et al., 2022).

Several rural COPD investigations are underway, including one 6-year study of4,000 individuals examining regional differences in disease rates of COPD and other diseases in rural Appalachia and the Mississippi Delta. Another 5-year study is determining whether a short questionnaire and breathing test can help identify more people with COPD in primary care settings, potentially improving their quality of life and outcomes. Yet another investigation is exploring whether video telehealth pulmonary rehabilitation lessens COPD-related hospital readmissions and improves quality of life. Some rural counties already have used pulmonary rehabilitation programs to improve health outcomes and quality of life of these individuals (Doyle et al., 2017).

A recent systematic review of six telehealth and five non-telehealth self- management interventions delivered to rural adults with COPD, was promising in showing how telehealth interventions could be as useful as non-telehealth interventions for improving COPD self-management (Stellefson et al., 2022). Another systematic review and meta-analysis of 19 studies comparing the effect of minimal equipment and exercise equipment-based programs on exercise capacity, health-related quality of life, and strength in pulmonary rehabilitation. There was no difference between the two programs for either exercise or strength, but better health-related quality of life was seen when using minimal equipment. These findings suggest pulmonary rehabilitation programs using minimal equipment may be a suitable intervention where access to gymnasium equipment is limited, as in rural areas (Cheng et al., 2023). Some of these studies and others can be identified by using the COPD National Action Plan Community Action Tool., a public, online categorical list of activities for key stakeholders such as rural nurses who desire to implement useful interventions to improve the quality of care they provide for individuals living with COPD (NHLBI, 2021; 2023).

References

Cheng, S. W. M., McKeough, Z. J., McNamara, R. J., & Alison, J. A. (2023). Pulmonary rehabilitation using minimal equipment for people with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Physical therapy, 103(5), pzad013. https://doiorg.uab.idm.oclc.org/10.1093/ptj/pzad013

Croft, J. B., Wheaton, A. G., Liu, Y., et al. (2018). Urban-rural county and state differences in chronic obstructive pulmonary disease — United States, 2015. MMWR: Morbidity & Mortality Weekly Report, 67, 205 211. http://dx.doi.org/10.15585/mmwr.mm6707a1

Doyle, D., Tommarello, C., Broce, M., Emmett, M., & Pollard, C. (2017). Implementation and outcomes of a community-based pulmonary rehabilitation program in rural appalachia. Journal of Cardiopulmonary Rehabilitation and Prevention, 37(4), 295–298. https://doi.org/10.1097/HCR.0000000000000247

Gaffney, A. W., Hawks, L., White, A. C., Woolhandler, S., Himmelstein, D., Christiani, D. C., & McCormick, D. (2022). Health care disparities across the urban-rural divide: A national study of individuals with COPD. The Journal of Rural Health, 38(1), 207–216. https://doi.org/10.1111/jrh.12525 

NIH: National Heart, Lung, and Blood Institute. (2021, February). COPD National Action Plan: Community Action Tool. https://cnap.nhlbi.nih.gov/index.php/

NIH: National Heart, Lung, and Blood Institute. (2023, November 15). Making strides to address COPD in rural communities. https://www.nhlbi.nih.gov/news/2023/making strides-address-copd-rural-communities

Stellefson, M., Kinder, C., Boyd, I., Elijah, O., Naher, S., & McFadden, N. (2022). COPD self-management for adults living in rural areas: Systematic review of telehealth and non-telehealth interventions. American Journal of Health Education, 53(5), 269–281. https://doi.org/10.1080/19325037.2022.2100525

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Almost 90,000 people in the U. S are diagnosed with Parkinson’s disease annually and 1.2 million individuals are estimated to have this chronic illness by 2030 (Willis et al., 2022). The leading risk factor is age or those who are 65 years and older. Males also have a higher prevalence. Genetic and environmental factors also play a significant role. A higher incidence is found in topographical areas of the “Rust Belt” located in the midwestern and northeastern areas of the U.S., specifically Southern California, Southeastern Texas, Central Pennsylvania, and Florida (Parkinson’s Foundation, 2022).

Rural areas also are impacted because of the increased risk to farmers from pesticides (Shrestha et al., 2020). Use of amphetamine or methamphetamine, heavy metals, air pollution, traumatic brain injury, and trichloroethylene (Ascherio & Schwarzschild, 2016; De Miranda et al., 2022) found in ground water (The MNT Editorial Team. 2021) are other risk factors.

So, how can rural health professionals assist rural individuals and their families who are impacted by Parkinson’s disease? Support groups in rural areas are beneficial to both patients with Parkinson’ s disease and their family members. A key factor is communication, providing interactions to enhance education in sharing and learning valuable information about the disease and its management from both expert guest speakers as well as individuals with Parkinson’s disease who have similar symptoms. Another significant component of communication is emotional support that occurs from these interactions to decrease isolation and enhance the development of social activities among group members (Bush et al., 2018).

Strategies for encouraging both online and face-to-face support groups are to post local flyers and make public announcements about meeting times and Parkinson’s topics in common places and through local avenues (radio, grocery stores, beauty shops), especially when guest speakers ae talking management strategies for common issues. Using public places with handicapped access, such as libraries, schools, etc. also is valuable in enhancing these support groups. Another option is to start a statewide website and newsletter to provide information about Parkinson’s disease and engage rural stakeholders (Bush et al., 2018).

The Parkinson’s Foundation (2024) also provides resources and support for health providers, as well as for individuals with Parkinson’s disease and their care partners, including an online global network for identifying treatment centers, as well as online communication groups, educational materials, and monthly podcasts. This organization currently offers grants to rural communities that focus on education and exercise programs, address mental health issues, and provide support for care partners. Together, we can enhance the lives of those with Parkinson’s and their family members.

References

Ascherio, A., Schwarzschild, M. A. (2016). The epidemiology of Parkinson’s disease: Risk factors and prevention. Lancet Neurology, 15(12), 1257-1272. https://doi.org/10.1016/S1474-4422(16)30230-7 25

Bush, E. J., Singh, R. L., Hidecker, M. J. C., & Carrico, C. P. (2018). Parkinson’s disease support groups in rural America: Barriers, resources, and opportunities. The Qualitative Report, 23(6), 1381-1400. https://nsuworks.nova.edu/tqr/vol23/iss6/8

De Miranda, B. R., Goldman, S M., Miller, G. W., Greenamyre, J. T., & Dorsey, E. R. (2022). Preventing Parkinson’s disease: An environmental agenda. Journal of Parkinsons Disease, 12(1), 45-68. https://doi.org/10.3233/JPD-212922

Parkinson’s Foundation. (2022). Prevalence and incidence. https://www.parkinson.org/understanding-parkinsons/statistics/prevalence-incidence

Parkinson’s Foundation. (2024). Better lives. Together. https://www.parkinson.org/

Shrestha S., Parks C. G., Umbach D. M., Richards-Barber, M., Hofmann, J. N., Chen, H., Blair, A., Beane Freeman, L. E., & Sandler, D. P. (2020). Pesticide use and incident Parkinson’s disease in a cohort of farmers and their spouses. Environmental Research,191, 110186. https://doi.org/10.1016/j.envres.2020.110186

The MNT Editorial Team. (2021). What are the risk factors for Parkinson’s disease? https://www.medicalnewstoday.com/articles/323440

Willis, A. W., Roberts, E., Beck, J. C., Fiske, B., Ross, W., Savica, R., Van Den Eeden, S. K., Tanner, C. M., Marras, C., & Parkinson’s Foundation P4 Group (2022). Incidence of Parkinson disease in North America. NPJ Parkinson's Disease, 8(1), 170. https://doi.org/10.1038/s41531-022-00410-y

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

While nearly 60 million residents live in rural areas, only 10% of general surgeons provide healthcare to these individuals. These rural patients also face many barriers, such as lower yearly incomes, inadequate health insurance coverage, a higher incidence of more complex chronic illnesses, and geographical barriers to sufficient healthcare to meet their needs. However, surgeons offer both physical and economic benefits to rural communities (e.g., almost $1-3 million/year in financial worth and 40% of revenues of small rural hospitals; Sarap, & Reiss, 2024).

These rural health providers have significant caseloads with inadequate relief coverage (e.g., every 2 to 3 days), which impacts their recruitment to rural areas (Sarap, & Reiss, 2024). Unfortunately, older surgeons also are facing retirement and there is a lack of surgeons willing to move to rural areas, instead choosing to specialize in selective illnesses. Compounding the significant demands of their practice, these rural surgeons and supportive health providers are significantly impaired without adequately equipped diagnostic and laboratory facilities and operating rooms (Kirby Surgical Center, 2024). Time, technology, and geographical constraints also impact rural surgeons’ and other health providers’ need to learn the latest surgical advancements for their patients (Sarap, & Reiss, 2024).

There is a need to develop innovative ideas for addressing these healthcare needs of rural individuals, surgeons, and other healthcare providers. Creative models designed to enhance rural surgical treatment and enhance skilled practitioners include those who offer or desire the following:

• 1)       Utilizing telesurgery in which surgeons who live in non-rural areas perform surgery remotely through robotic and computer-assisted technology;
• 2)       Offering E-consultations that enhance rural and urban collaboration about complex patients and chronical illnesses and medical and surgical treatment options;
• 3)       Offering rural surgical training of health providers, such as nurses and general surgeons;
• 4)       Providing skilled surgeons, anesthetists, and nurses to staff rural surgical mobile units to treat emergencies and select surgeries;
• 5)       Establishing shared services (e.g., diagnostic procedures, treatment, after-care), and physical (e.g., equipment, medications), and personal resources (specialists traveling to rural communities during specified time frames);
• 6)       Utilizing rural resources (e.g., community health workers) and other health professionals (e.g., home health nurses) who can identify patients who need potential surgeries;
• 7)       Offering financial rewards (e.g., loan repayments; scholarships, housing) to surgeons and surgical healthcare personnel who relocate to rural areas;
• 8)       Fostering new rural healthcare personnel (e.g., surgeons, anesthetists, and nurses) to be mentored by more advanced practitioners so they can then apply these skills in their rural practice;
• 9)       Encouraging continuing education and professional development of newer surgical skills through on-line and face-to face training; and
• 10)   Encouraging health providers to take advantage of rural training programs that prepare these individuals to practice and provide excellent surgical care in rural settings (Kirby Surgical Center, 2024).

References

Kirby Surgical Center (2024). Challenges and solutions in rural surgical health services. Challenges and Solutions in Rural Surgical Services (kirbysurgicalcenter.com)

Sarap, M., & Reiss, A. D. (2024). Rewards and frustrations of rural surgery practice. American College of Surgery. https://www.facs.org/for-medical-professionals/practice-management/private-practice-small-business/rural-surgery-practice/

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Over thirty million American have diabetes mellitus, with Type 2 (T2DM) the most common (CDC, 2024b). Unsurprisingly, T2DM is also more prevalent in rural America, (10% in rural compared to 8% in urban areas), with higher mortality rates. Potential health challenges contributing to these death statistics include more comorbidities exacerbating this chronic condition, difficulty in obtaining continuing diabetes treatment and in obtaining heart-healthy foods, and environmental factors (Dugani et al., 2022). A family history of T2DM, excessive weight, inadequate exercise, older age, and having certain racial and ethnic lineages (i.e., Alaska Native, American Indian, African American, Hispanic, and Asian or Pacific Islander) are other risks (University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis, 2020).

While research indicates diabetes self-management education and support (DSMES) are particularly important, over 60% of rural neighborhoods are without this asset (CDC, 2024b). DSMES provides preventative interventions, improves glycemic control, self-confidence, and quality of life, with fewer complications, emergency care, and hospitalizations. Resources (CDC, 2024a; 2024c) for both T2DM health professionals and patients include the following:

• DSMES Toolkit provides a variety of tools and guidelines for DSMES services.
• Diabetes Self-Management Education and Support in Adults with Type 2 Diabetes: A Consensus Report suggests DSMES resources and improves upon patients' outcomes, potential solutions to barriers, and information about the needs of those with T2DM (Powers et al., 2020).
• Referral Process offers DSMES information and support.
• When Diabetes Self-Management Education Is Emergency Medicine suggests strategies for managing DSMES.
• Association of Diabetes Care & Education Specialists (ADCES) offers education programs by zip code and states.

• Education and Support Information sends patients this patient-friendly information on how DSMES services can help people with diabetes learn how to take care of themselves.

Medicare will reimburse 10 hrs. of DSMES if health providers meet certain guidelines for billing. Fortunately, yearly training is available either after the initial benefit period or beginning in January of the following year (ACDES; 2022). While reimbursement to private payers varies, some may follow guidelines provided by the Centers for Medicaid and Medicare Services, possibly because of cost savings in reducing costs for acute emergencies and co-morbidities. Seeking programs that provide funding to providers for DSMES services offered to uninsured individuals with T2DM offers many benefits, but providers must be patient in identifying these resources to enhance diabetes care.

References

Association of Diabetes Care & Education Specialists (ACDES; 2022). Frequently asked questions: DSMES AND DSMT reimbursement. https://www.adces.org/docs/default-source/default-document-library/ask-the-reimbursement-expert-faq-2022-final.pdf?sfvrsn=f0b49158_0

Centers for Disease Control and Prevention (CDC, 2024a). Referring patients to DSMES. https://www.cdc.gov/diabetes/hcp/dsmes/index.html

Centers for Disease Control and Prevention (CDC, 2024b). Rural health: Diabetes self-management in rural America as a public health issue. https://www.cdc.gov/rural-health/php/public-health-strategy/public-health-considerations-for-diabetes-self-management-education-and-support-in-rural-america.html

Centers for Disease Control and Prevention (CDC, 2024c). About diabetes self-management education and support. https://www.cdc.gov/diabetes/education-support-programs/index.html

Dugani, S. B., Wood-Wentz, C. M., Mielke, M. M., Bailey, K. R., & Vella, A. (2022). Assessment of disparities in diabetes mortality in adults in U.S. rural vs. nonrural counties, 1999–2018. JAMA Network Open, 5(9), e2232318. https://doi.org/10.1001/jamanetworkopen.2022.32318

Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M, Harms, D., Hess-Fischl, A., Hooks, B., Isaacs, D., Mandel, E. D., Maryniuk, M. D., Norton, A., Rinker, J., Siminerio, L. M., Uelmen,& Sachaet, A. L. (2020). Diabetes self-management education and support in adults with type 2 diabetes: A consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. The Diabetes Educator, 46(4), 350-369. https://doi.org/10.1177/0145721720930959

University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis. (2020). Rural diabetes prevention and management toolkit [online]. Rural Health Information Hub. https://www.ruralhealthinfo.org/toolkits/diabetes

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Life is on a continuum from birth to death, but aging is a natural process. As we age, we encounter a variety of significant changes in our daily lives--career transitions, children growing up and leaving home, loss of loved ones, physical and psychosocial illnesses, and sometimes, changes in our ability to perform many activities of daily living. While many of us know of older individuals who can outperform us in many activities, as we age, we often experience more chronic illnesses. Individuals who live in rural locations have a higher risk for high cholesterol and blood pressure, obesity, arthritis, depressive disorder, diabetes mellitus, COPD, and heart disease (Research Triangle Institute, 2023).

As health professionals, how we meet the needs of older individuals as they face these challenges is key and a high priority in developing effective interventions. A review of 40 empirical studies confirmed older individuals face physical and psychosocial challenges and require supportive interventions directed toward their social activities and relationships, psychological well-being, mobility, self-care, and domestic life. While these individuals desire independence in managing their illness, they lack strategies health professionals can provide regarding self-care, communication, coordination of services, and knowledge about various care pathways and support servicesto enhance quality-of-life (Abdi et al., 2019). The Rural Health Information Hub (2022) and others also offer many resources for health providers.

A few strategies for these individuals include:

• ·       suggesting purposeful activities that facilitate active functional roles, such as mentoring activities (teaching preschool and school-age reading; volunteer activities; Owen et al., 2022);
• ·       providing information about developing heart healthy nutritional eating habits, quality rest and sleep habits, and mobility (e.g., with adapted exercises);
• ·       encouraging using mental stimulation activities (e.g., reading, learning new skills and hobbies), social connections (e.g., family, friends, etc., community volunteer and work groups), and emotional support (refer for counseling, telephone or face-to-face support groups, developing new hobbies) to enhance mental and emotional well-being;
• ·       teaching strength training, fall prevention and safety strategies for those who have difficulty in performing daily activities;
• ·       encourage interactions with family and friends and participating in community activities to facilitate enjoyable activities;
• ·       offer classes that focus on strength training, aerobic exercise, dietary skill building, and/or civic engagement (RIH Hub, 2022);
• ·       use trained community health workers and coaches to offer information about various illnesses such as hypertension, diabetes, mellitus, heart disease etc. (RIH Hub, 2022);
• ·       offer mobile screening clinics for chronic conditions (e.g., high blood pressure and cholesterol, obesity, diabetes mellitus, arthritis, COPD, etc. RIH Hub, 2022); and
• ·       engage rural community-based organizations, leaders, health-care systems, and providers to offer programs to enhance the well-being of older adults;

References

Abdi, S., Spann, A., Borilovic, J., de Witte, L., & Hawley, M. (2019). Understanding the care and support needs of older people: A scoping review and categorisation using the WHO international classification of functioning, disability and health framework (ICF). BMC Geriatrics, 19(1), 195. https://doi.org/10.1186/s12877-019-1189-9

Owen, R., Berry, K., & Brown, L. J. E. (2022). Enhancing older adults' well-being and quality of life through purposeful activity: A systematic review of intervention studies. The Gerontologist, 62(6), e317–e327. https://doi.org/10.1093/geront/gnab017

Research Triangle Institute (2023). Overlooked Americans: The toll of chronic disease in rural America. https://healthcare.rti.org/insights/chronic-disease-and-rural-health-disparities#:~:text=Rural%20health%20disparities%20%2D%20One%20nation%2C%20divided&text=Across%20the%20spectrum%20of%20chronic,non%2Dmetropolitan%20than%20metropolitan%20areas

Rural Health Information Hub ([RHI Hub] 2022). Chronic disease in rural America – Models and innovations. https://www.ruralhealthinfo.org/topics/chronic-disease/project-examples

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Empirical data support an imbalance in accessing quality health care and the need to test innovative solutions to deliver quality healthcare to farmers and their families. These individuals are receptive to solutions that provide reasonable, dependable, and cost-effective health care, including virtual health care platforms. As expected, some major issues farmers’ report includes not being able to access quality medical care in view of a shortage of rural health providers. The time it takes to travel long distances to medical appointments and limited access to telemedicine are other significant barriers. These individuals desire quality health care that is affordable, accessible, consistent, sufficient, and flexible care around their busy daily lives.

Desired interventions are those which provide formal, affordable, and cost-effective health care, physical and psychosocial well-being and health programs, and affordable costs in accessing health insurance. While farmers are willing to use virtual health care for many of their medical needs, a significant constraint is smart phone costs and a lack of high-speed internet, although virtual visits commonly are cheaper when comparing to traveling long-distances to health providers. These individuals report other issues regarding isolation, time, and inadequate peer and co-worker support for integrating healthy daily lifestyle interventions. Farmers desire accessible and flexible support programs that address strategies to improve their overall health and well-being, as well as safety training (e.g., injury prevention, first aid training; Wright et al., 2021).

So, how do policymakers and health system leaders support farmers? The NRHA (2024) and other agencies (Farm Foundation, 2022; University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis, 2022, 2024; Wright et al., 2021; Yazd et al., 2019) suggest we support legislation and offer agendas to improve the quality and well-being of these rural individuals, through:

• 1.     additional rural support programs that offer fiscal support to healthcare facilities to improve community health and well-being;
• 2.     enhanced rural broadband access for access to distance learning and telemedicine programs;
• 3.     more assistance for emergency medical services and equipment to enable health personnel to respond during urgent situations;
• 4.     programs, hotlines, and resources focused on farmers who have physical and behavioral health issues and mental health crises;
• 5.     food security plans to address rural health disparities and healthy lifestyles;
• 6.     support programs to provide physical and psychosocial support for healthy lifestyles, as well as safety training; and
• 7.     more opportunities for accessing peer and co-worker support.

References

Farm Foundation. (2022). Perspective: Farmer mental and physical health as components of sustainability. https://www.farmfoundation.org/2022/07/20/perspective-farmer-mental-and-physical-health-as-components-of-sustainability/#:~:text=These%20include%20FarmAid%2C%20Avera%20Farmer%20and%20Rural%20Stress,cope%20with%20farm%20related%20stress%20%28Farm%20Credit%2C%202020%29

National Rural Health Association (NRHA). (2024). Farm bill priorities. https://www.ruralhealth.us/nationalruralhealth/media/documents/advocacy/advocacy%20leave-behinds%202024/farm-bill-priorities.pdf

University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis. (2022). Rural Suicide Prevention Toolkit [online] Rural Health Information Hub. https://www.ruralhealthinfo.org/toolkits/suicide

University of Minnesota Rural Health Research Center and NORC Walsh Center for Rural Health Analysis (2024). Mental Health in Rural Communities Toolkit [online] Rural Health Information Hub. https://www.ruralhealthinfo.org/toolkits/mental-health

Wright, N., Scherdt, M., Aebersold, M. L., McCullagh, M. C., Medvec, B. R., Ellimoottil, C., Patel, M. R., Shapiro, S., & Friese, C. R. (2021). Rural Michigan farmers' health concerns and experiences: A focus group study. Journal of Primary Care & Community Health, 12, 21501327211053519. https://doi.org/10.1177/21501327211053519

Yazd, S. D., Wheeler, S. A., & Zuo, A. (2019). Key risk factors affecting farmers’ mental health: A systematic review. International Journal of Environmental Research and Public Health, 16(23), 4849. https://doi.org/10.3390/ijerph16234849

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

About 1 million infants and toddlers live in rural areas in the U. S., with many parents facing challenges, such as an inadequate number of healthcare providers and a need to travel long distances to access them, transportation issues, and lower income levels. In fact, rural mothers are less likely to receive adequate prenatal care than those who live in urban areas, with mothers living in Arizona (13.7%), Alabama (9.9%), North Dakota (8.2%), South Dakota (7.4%), and Wyoming (5.9%) with the highest percentage point difference when comparing rural and urban states (Keating et al., 2020; Centers for Medicare & Medicaid Services, 2019). Women who live in the Southeastern and Southwestern U.S. also have higher rates of inadequate prenatal care (Laurore et al., 2022). Unplanned home births in rural areas are primarily assisted by “other” individuals (68.1% in rural areas; 24.3% in urban areas) rather than certified healthcare providers US DHHS; 2019). These data suggest an increased risk for complications because “other” individuals may be less well-prepared in managing maternal and infant complications. Preventive health and dental visits also are fewer in rural areas, perhaps due to a lack of health insurance (Keating et al., 2020).

Negative health outcomes in rural areas are many. Unfortunately, infant mortality and preterm birth rates are higher in rural communities than in urban areas (CDC, 2019b; Ely & Hover, 2018). Three of the five leading deaths, congenital malformation, sudden death syndrome, and unintentional injuries are higher in rural areas compared to urban ones. Although rural infants are less likely to die from birthweight and maternal complications when compared to their urban counterparts, some rural states such as Mississippi have higher rates of lower birthweight rates (12.5%) (Ely & Hover, 2018). Breastfeeding rates also are lower in rural areas than in urban ones (CDC, 2019a), perhaps due to limited access to breastfeeding programs (Keating et al., 2020).

So, how do we support infants, toddlers, mothers, fathers, and significant others, as rural healthcare providers? Laurore and colleagues (2020) suggested several strategies including:

• 1)    assisting families to enroll their infants in their state’s Children Health Insurance Program (CHIP) that is designed to provide insurance to families not eligible for Medicaid;
• 2)    investigating other methods to provide health services, such as mobile health clinics and telemedicine for well-child and ill-focused visits, including video conferencing and telephone and email contacts;
• 3)    encouraging appropriate vaccinations for all rural families, utilizing resources such as the Vaccine for Children (VFC) program that provides vaccinations to children under 19 years old who are without insurance, those eligible for Medicaid, and those of either an American Indian or Alaska Native race/ethnicity (CDC, n.d.);
• 4)    utilizing state public health departments through task forces or directives to identify strategies for meeting gaps in home visiting programs; and
• 5)    developing relationships with community resources (e.g., hospitals, birthing centers, and mobile health clinics, etc.) to provide group prenatal visits, etc.

These statistics indicate potential gaps which rural healthcare providers can fill by being creative in providing care. State and federal funding and other community resources enable health professionals to provide more comprehensive care to these individuals prior to, during, and after birth.

Centers for Disease Control and Prevention (CDC; n.d.). Vaccines for Children Program (VFC). https://www.cdc.gov/vaccines/programs/vfc/about/index.html

Centers for Disease Control and Prevention. (CDC; 2019a). Breastfeeding facts. https://www.cdc.gov/breastfeeding/data/facts.html

Centers for Disease Control and Prevention (CDC; 2019b). Infant mortality. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm#about

Centers for Medicare & Medicaid Services. (2019). Improving access to maternal health care in rural communities. https://www.cms.gov/About-CMS/AgencyInformation/OMH/equity-initiatives/rural-health/rural-maternal-health

Ely, D. M. & Hoyert, D. L. (2018). Differences between rural and urban areas in mortality rates for the leading causes of infant death: United States, 2013-2015. https://www.cdc.gov/nchs/data/databriefs/db300.pdf

Keating, K., Cole, P., & Schaffner, M. (2020). State of babies yearbook: 2020. Washington, DC: ZERO TO THREE.

Laurore, J., Baziyants, G., & Daily, S. (2020). Health care access for infants and toddlers in rural areas. https://cms.childtrends.org/wp-content/uploads/2020/07/Rural-health-iniquities_ChildTrends_July2020.pdf

United States Department of Health and Human Services (US DHHS; 2019), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics, Natality public-use data 2018, on CDC WONDER Online Database, September 2019. http://wonder.cdc.gov/natalityexpanded-current.html

This blog post was prepared by RNO Website Committee Chair Joan Grant Keltner.

Vaccinations are a cost-effective intervention to prevent unnecessary morbidity and mortality associated with infectious diseases in children and adolescents. The National Immunization Survey–Child reported no decrease in routine vaccinations, even children born during the COVID-19 pandemic, except for those children living below the federal poverty level and in rural areas (CDC, 2022; Hill, 2023). Yet, a significant percentage of adolescents in rural communities are not getting recommended vaccines, especially HPV (15%) and meningococcal conjugate (20%) vaccines to protect against serious diseases, when compared to those who live in urban areas (CDC, 2023). In a recent review of 120 studies, and a statistical meta-analysis of 95 of them, investigators sought to examine the effectiveness of various interventions for providing vaccination coverage to children and adolescents, ages 5 to 19 yrs. Among the various interventions, education about vaccines increased adherence by 19%, reminders and recalls (e.g., telephone and autodialed calls, mailed letters, postcards, text messages, e-mails, and a combination of these methods) by 15%, health providers’ interventions by 13%, monetary incentives (i.e., cash and gift vouchers) by 67%, and concurrent multi-level interventions (i.e., to schools, health providers, and health clinics) by 25%. The influence of using school-based clinics and policies and legislation for vaccinations is unclear and no significant impact was found from providing a combination of interventions together. Other statistical information (i.e., risk ratios and confidence intervals; types of interventions and specific vaccinations) are reported in the article (Siddiqui et al., 2022). These findings highlight the importance of using various methods to improve vaccination coverage in children and adolescents, with a need for further research in families living in rural areas and experiencing financial hardships.

CDC. (2022). Childhood vaccination coverage before and during the COVID-19 pandemic among children born January 2017–May 2020, National Immunization Survey-Child (NIS-Child), 2018–2021. Atlanta, GA: US Department of Health and Human Services. https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/pubs-presentations/nis-child-pandemic-effects-2018-2021.html

CDC. (2023). Vaccination in rural communities. https://www.cdc.gov/ruralhealth/vaccines/index.html

Hill, H. A., Chen, M., Elam-Evans, L. D., Yankey, D., & Singleton, J. A. (2023). Vaccination coverage by age 24 months among children born during 2018–2019 — National Immunization Survey–Child, United States, 2019–2021. Morbidity and Mortality Weekly Report, 72, 33–38. http://dx.doi.org/10.15585/mmwr.mm7202a3.

Siddiqui, F. A., Padhani, Z. A., Salam, R. A., Aliani, R., Lassi, Z. S., Das, J. K., & Bhutta, Z. A. (2022). Interventions to improve immunization coverage among children and adolescents: A meta-analysis. Pediatrics. 149(s6), e2021053852D

RNO members, we are trying to provide news on our RNO Blog about high priorities in caring for both infants and children.  Please provide your expertise to share with RNO members!  You may send your summaries to RNO Website Committee Chair Joan Grant Keltner, at grantj@uab.edu. Thanks for your participation!