State of the Rural Health and

Disability Science

Overview• A Story• Rural disability and

health issues• Health promotion• Expanded the

purview of our work

Sanders County • Family of 3 adults

– Power wheelchair user– Sibling with significant

developmental disability– Adult with mental illness

• Living Independently• Few needs for support

Rural Health• Managing funding loss• Medicare policy • Attracting qualified

personnel• Maintaining Hospitals

Clark Fork Valley Community HospitalSanders County, Montana

Disability and Rural Health

• People with disabilities face all of the same generic rural health challenges

• Additional Challenges– Lack of specialists– Lack of accessible medical diagnostic technology– Transportation for services

• “Narrower margin of health” (Pope & Tarlov, 1991)

Health Promotion• Health promotion can

help address the narrower margin of health

• Health Psychology and Behavioral Medicine

• 2000-2010 Decade of Behavior

The Role of the Environment

• Individual vs. Environment• Disability results from the

interaction of person and environmental factors.

• International Classification of Function, Disability and Health (WHO, 2001)

Living Well with a Disability• Living Well Editions 1 - 3

– Original pilot – 1990– Randomized trial 1998

• Training program 2000• Fourth Edition 2010

– Peer support and self-advocacy

• Community Activated Living Well

• Participatory Curriculum Development

Current RTC Health Projects• Peer Support for

Mental Health Symptoms

• Consumer Activated Self-Management

• Participatory Curriculum Development

Policy Impacts• New Freedom Initiative named Living

Well as a national program of significance to be emulated.

• National Center on Birth Defects and Developmental Disabilities names Living Well as an evidence-based practice

• Aging and Disability Resource Centers include Living Well

• Montana Medicaid recently included health promotion as a reimbursable services

Community-Level Interventions• National trends toward

community interventions• Our experience and

observations• The challenge of

community level interventions

Vincent Francisco

Dr. Vincent Francisco is the Director of Graduate Study in the Department of Public Health Education at the University of North Carolina at Greensboro

Rural Health and Disability: Potential Contributions from Public Health

Vincent T Francisco and Craig Ravesloot

Presentation for the State of the Science: Toward a New Paradigm for Rural America Conference, 20 April 2012.

Intro and Background

• Rural people are less healthy than urban people (Institute of Medicine, 2005)

• Rural environments have fewer healthcare resources to address health problems and to promote health of rural populations

• The cause of this disparity goes well beyond access to healthcare, the focus of most rural health researchers and advocates

What Public Health Brings to the Table

• Mission of Public Health – “Assuring the conditions under which health can occur”

• Focus on access to care and on primary prevention

• Potentially helpful data focusing on population outcomes, rather than individual deficits

• Value of democratic inclusiveness• Focus on improvement of broader environmental

and social conditions

The Ecology of Rural Health

Several theoretical approaches offer some helpful framing, especially:• Theories of human development

• Theories of behavioral influences

• Theories of systems and related outcomes

Ecological Model of Rural Health

Environmental Variables• Social• Physical

Personal Variables

• Biology

• History

(adapted from Horowitz, 1987)

Optimal Developmental Outcome

FacilitativeNon-Facilitative

Facilitative

Structural/Behavioral Model of Development

Socio-ecologic Model of Human Development

(Bronfenbrenner, from McLaren et al., 2005)

Socio-Ecological Model in PH • Intrapersonal factors—characteristics of the individual such as

knowledge, attitudes, behavior, self concept, skills, etc. This includes the developmental history of the individual.

• Interpersonal processes and primary groups—formal and informal social network and social support systems including the family, work group, and friendship networks.

• Institutional factors—social institutions with organizational characteristics. And formal (and informal) rules and regulations for operation.

• Community factors—relationships among organizations, institutions. And informal networks within defined boundaries.

• Public policy—local, state, and national laws and policies.

(from McLeroy et al., 1988)

BEM Diagram of Two Hierarchical Systems that Combined Help Explain Both Individual and Cultural Practices

Earlier Time Later Time

Exte

rnal

Influ

ence

sIn

tern

al In

fluen

ces

Context Consequences

Social/Cultural LevelNationality

Culture Specific

Community LevelPolicies

LawsMedia

Local LevelClinical Services

Built and Social Environment

Individual LevelNormative Group

Physical

Learning History

Physiology

Anatomy

Genome

Behavior

Theory of Triadic Influence

Levels of Causation

Ultimate Underlying Causes

Distal Predisposing Influences

Proximal Immediate Predictors

Personal Stream

Social Stream

Environmental Stream

Nurture/CulturalBiological/Nature

Social/Personal Nexus

Evaluations and Expectations

Affect and Cognitions

Decisions

Experiences

Biology/Personality Social Situation Cultural Environment

Sense of Self/Control

Social Competence

Self Determination

Skills: Social + General

Self-Efficacy, Behavioral Control

Social Normative Beliefs Attitudes Toward the Behavior

Decisions/Intentions

Trial Behaviors and Experiences

Behavior Related Behaviors

Interpersonal Bonding

Others’ Behs and Atts

Motivation to Comply

Perceived Norms

Interactions w/ Soc Inst’s

Information/Opportunities

Values/Evaluations

Knowledge/Expectancies

Synergy of Efforts and Syndemics

• Syndemics is the interaction of multiple epidemics

• Can be behavioral problems, not just epidemiological problems

• Offers an approach to framing the problem outside of “blaming the victims”

Minimum Boundary for Syndemic Thinking

Health

LivingConditions

Capacity toAct

Adapted from a Syndemics presentation by Bobby Milstein, PhD (CDC Office of the Director)

• Two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population.

Systems ScienceBasic Problem Solving Orientations

Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

Event Oriented View

Problem Results

Goals

Situation

Decision

SideEffects

Systems ViewGoals

Environment

Decisions

Goals ofOthers

Actions ofOthers

Adapted from a Syndemics presentation by Bobby Milstein, PhD (CDC Office of the Director)

Systems Improvement for Health Outcomes

• Community Engagement in problem definition and solution development

• Integration of a systems improvement approach including feedback mechanisms related to ongoing improvement

• Resulting in a few big systems improvements, and a lot of smaller ones

Model for Health Promotion and Community Development(Fawcett et al., 2000)

Community Context & Planning

Community Action &

Intervention

Community & Systems Change

Risk & Major Behavior Change

Community Level

Outcomes

7 Factors Related to Success

• Targeted Vision and Mission• Leadership (charismatic and distributive)• Action Planning• Capacity Building• Paid Staff• Documentation and Feedback• Making Outcome Matter

Rural Environment and Disability

Rural health issues are exacerbated by several factors, including:• Lack of mobility and physical access to services• Fewer services available due to economic

factors• Increased negative effects due to

marginalization and lack of communication and engagement in decision-making

Case Study 1 – North Carolina

• 4 counties in North Carolina as a pilot project• Focus on the needs of families of children with special

health care needs (defined broadly)• Input from the families and the broader community

resulted in several hundred potential systems improvements across the 4 counties

• Most improvements were sought in transportation, communications, access to services, availability of services, and availability of support services for the families and children

Case Study 1 (cont.)

• 3 years of implementation resulted in over 120 systems improvements across the 4 counties (low of 20 and high of over 60 within individual counties)

• Many service providers are adding advisory boards to their agencies that include the families

• Plans are underway to extend the planning and collective action to sectors not already covered

Case Study 2 – Rural South Carolina

• Adaptation and adoption of “Living Well with a Disability” program

• Phase 1: meeting with stakeholders• Phase 2: relationship building• Phase 3: working group established to adapt

curriculum• Phase 4: self-assessment of program

effectiveness

Case Study 2 (cont.)• Program materials were used beyond the initial program

period and commitments made were honored• One DSB consumer moved into his own apartment and

participated with other DRC staff and clients in the “Medicaid Matters” rally in Washington, DC, June 2010

• Inclusion and participation of consumers can enhance individual behavior and system behavior that promotes health of community members

• Inclusion of DSB clients in the development of the program structure and materials was a key to the program’s success

Conclusions• People with disabilities face substantial challenges to maintaining

health status.

• With fewer economic and other social resources to draw on, they are at a distinct disadvantage for health behavior change and healthcare access despite their greater needs for support.

• Behavioral syndemics emerge that put individuals at risk for secondary conditions that require even greater access to specialty medical care.

• Novel solutions to these complex health problems that affect all rural people can emerge through a community systems approach.

• Organizing across public and private health sectors to create opportunities for community participation including health promotion holds promise for addressing these substantial problems and for meeting the needs of people with disabilities.

Conclusions (cont.)• Individuals are both responsible for their health and highly

influenced by the environment in which they live. • As long as community participation in rural communities is limited

by physical, economic, and social structures, the health of people with disabilities will be at risk.

• Community interventions that level the playing field for all community members will encourage both individual- and community-level behavior that improves health for all people.

Recommendations1. Include disability screening questions and county of residence on all health

related national data collection efforts to allow analysis of health status between the general population, people with disabilities, and rural people with disabilities.

2. Conduct epidemiological research that examines the relationship between rural residence, community participation, and health outcomes for people with disabilities.

3. Train rural healthcare providers to provide Self-Management Support by networking with community health resources including health promotion and disease prevention activities.

4. Conduct demonstration projects of community level health planning that involve people with disabilities using participatory research methods.

Discussion

Questions?Comments?