NC1171: Interactions of individual, family, community, and policy contexts on the mental and physical health of diverse rural low-income families
Statement of Issues and JustificationNational & Regional Priorities
This project focuses on the dynamic interactions among individual, family, community, and policy contexts on the physical and mental health outcomes for rural low-income families and extends the previous research conducted within the multistate projects NC223 and NC1011. In order to understand the health of rural families we must examine the relationships and interactions among policy, communities, and families and how these processes change over time. This is consistent with the USDA North Central region priority "Social Change and Development" as well as other national priorities calling for research that emphasizes understanding these interactions within the rural context. USDA has a long history of recognizing the distinct needs of rural people and places; including "Rural Development" as a significant area within the National Research Initiative (NRI) Competitive Grants Program. NRI priorities also include health issues such as the need to stem the rise in obesity by understanding the individual and environmental influences on this national problem. Other federal agencies are now following suit by prioritizing rural issues. In addition to the Federal Office of Rural Health Policy, the U.S. Department of Health and Human Services (HHS, 2002) identified the importance of addressing the needs of Rural America. In a July 2002 report of the Rural Task Force, "strengthening rural families" was listed as one of its five primary goals (HHS, 2002). One facet of family life that contributes to strong families and sustainable communities is health. Thus, more work is needed to understand how changing demographics and federal and state policies relating to health, public assistance and agriculture affect family health across time.
Issues of Importance
Good mental and physical health is important for quality of life. However, research shows that all residents of the United States do not experience good health. In particular, the incidence, prevalence, morbidity, and mortality rates for disease in rural populations are significantly higher than those in the general population (Gamm et al, 2003; Meit, 2004). A report by the National Center on Health Statistics (2001) demonstrates these disparities. Compared to their urban counterparts, rural adults are more likely to report physical inactivity, obesity, limitations in daily activity, and tooth loss. Death rates and causes of death are also disparate. Rural areas have higher infant, child, and adolescent mortality rates than urban areas. Rural adults also are more likely to die from cardiovascular disease, motor vehicle accidents, and suicide (NCHS, 2001).
The previous multistate projects (NC223 and NC1011) focused on general family well-being, which included some health indicators. Health, however, was not the primary focus and therefore a limited amount of health related information was collected, constraining the nature and depth of possible health-related conclusions. Despite this, research findings to date clearly indicate that health is a crucial element of rural family well-being that requires further exploration. For example, Simmons, Huddleston-Casas, and Berry (2007) found that rural low-income postpartum women were unlikely to recognize their depression. Another study found that health insurance status and having a regular doctor enabled rural low-income women to access a physician when needed (Simmons, Anderson, & Braun, 2008). These data suggest that more detailed health information will provide further insight into the challenges facing rural low-income families. In addition, because NC223/1011 designated family location according to rural-urban continuum codes (Butler & Beale, 1994), the projects were uniquely positioned to capture the nuances of individual, family, community, and policy influences on rural health. Few national data sets make this distinction, in favor of broad categories such as metropolitan and non-metropolitan or urban, suburban, and rural. However, these broad categories do not allow for a more in-depth understanding of how local variations in geographic regions affect family health and well-being. The current project will continue to use a precise measure of rurality (see methods) in order to draw on the previous data as well as collect additional data to help explain the physical and mental health of diverse rural low-income families.
Rural communities and families have unique issues and needs compared to their urban counterparts. Poverty rates are consistently higher in rural areas (ERS, 2007), and persistent, long-term poverty is much more common for rural families than urban families (Deavers & Hoppe, 1992; Imig, Bokemeier, Keefe, Struthers, & Imig, 1997; ERS, 2007). In addition, rural families experience less access to services (e.g., health care, child care, social services) and a less stable economic base (HHS, 2002). Further, rural communities are changing demographically with their populations becoming more diverse. For example, immigration from abroad accounted for one-quarter of the nonmetro population growth during 2003-2004 (ERS, 2005). But race and ethnicity is just one of many characteristics of the diversity of families living in rural communities. Other examples include race, age, disability, and family structure. Taken together, it is evident that examination of the rural context, as well as the diversity of families within the rural context, will provide a more complete understanding of the health of low-income rural families. Currently, we have very limited information on the interactions of individual, family, community, and policy contexts and the resulting impacts on physical and mental health.
Understanding the interactions occurring across contexts is most clearly delineated from an ecological systems perspective (Bronfenbrenner, 1979). The ecological framework organizes the contexts within which families function into a discrete series of nested systems encompassing societal norms and values, institutional structures, interactions between families and other systems, and the family system itself. Collectively referred to as the ecosystem, these systems are interdependent; they exhibit mutual influence. Most research on families focuses on only one system level and does not look at the interactions among the levels, but research generated from NC223/1011 has demonstrated that multiple contexts influence individual and family well-being. This project will examine all of the system levels to determine impacts on the physical and mental health outcomes of individuals living in rural low-income families.
We intend to examine a number of health outcomes for both adults and children. Drawing on and then adding to the NC223/1011 dataset, we will examine: (a) duration and severity of chronic health conditions of adult(s) and children (e.g., obesity, diabetes, asthma, arthritis, and cardiovascular disease); (b) health effects on daily living (e.g., lost days of work and school, perceptions of impact); (c) mental health status for both adults and children (e.g., general mental health, depression, anxiety, behavior problems, and substance use/abuse); and (d) access to care (e.g., source of health care, perceptions of available care in the community, descriptions of primary, specialty, and emergency services utilization).
Family & Individual Context Family and individual level characteristics (e.g., ethnicity, age, disability) and practices have a major impact on the mental and physical health of family members. At the most basic level, heredity is an important characteristic in disease transmission. Individuals with a family history of cardiovascular disease (Patel et al., 2007), certain cancers (Martin et al, 2007; Rijn, 2007; Willems, 2007), and diabetes (Eisenbarth, 2007) are at higher risk for developing the disease themselves. Additionally, health practices in families, such as dietary choices, exercise habits, and health care utilization are all influenced by experiences within the family of origin.
Community Context There are important community factors that affect health care access and subsequent health as well. One factor is the limited physician supply (Schur & Franco, 1999). Rural Americans constitute 20% of the U.S. population, but only 9% of physicians practice in rural counties (Ricketts, 1999). Specialty physicians are also lacking (Rosenblatt & Hart, 1999). New and more advanced medical technologies spread slowly in rural areas, so the communities' health needs go unmet (Ricketts, 1999). In addition, rural public health systems are insufficient. Data show that rural public health personnel are more likely to work part-time and less likely to have formal public health training (Rosenblatt, Casey, & Richardson, 2002). Rural mental health care systems demonstrate similar challenges. There are few qualified professionals and limited service outreach (Spoth, 1997; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994). There also has been very little programmatic research on preventive mental health interventions (Spoth, 1997). Consequently, rural mental health systems are modeled after urban systems with little attention to the unique needs of rural residents (Arons, 2000). These infrastructure issues are compounded by the social stigma associated with having and receiving treatment for a mental illness (Arons, 2000). Beyond community factors affecting health care access, opportunities for healthy living also contribute to individual and family health outcomes. We intend to examine opportunities within communities for active play and recreation for children and adults. Recent research has linked nature and green space to improved outdoor play and recreational opportunities and participation in organized sports, yet these areas need additional research attention.
The mental and physical health of individuals and families has been addressed both directly and indirectly through policy efforts directed at the health of low income individuals and families (e.g., Medicaid, State Child Health Insurance Programs, childhood vaccination). Additionally, policies intended to contribute to family well-being, thus influencing mental and physical health, will be included (e.g., Temporary Assistance to Needy Families, Food Stamps, childcare assistance, housing assistance, Earned Income Tax Credit). States with unique policy efforts will be encouraged to examine those policies as well. For example, a policy impacting nutritional standards of food in school vending machines may be a state-specific effort. In addition, beyond policies enacted at the federal and state level, effects of the administration of the programs provided by these policies occurring at the county and community level will be assessed. For example, each state sets its own criteria for children's eligibility for free or reduced health care.
Interactions among Contexts
This project will examine the interactions among contexts in order to gain a better understanding of the health outcomes of diverse rural families. Examples of research questions that capture interactions between contexts include: If a community lacks sufficient family physicians, when and how do they decide to use emergency room services? Is there an interplay between housing accommodations (location, manufactured housing as a part of location), ownership, and access to health care? What is the relationship of neighborhood type and quality (i.e., mobile home versus subsidized housing) to children's outdoor activities? Have there been outreach programs in the community to address nutrition, physical activity, and obesity and how have families responded to these programs? To what extent does acculturation act as a barrier to healthier food and lifestyle choices?
A major challenge for this project is to investigate the interactions between systems. Therefore, to successfully complete this study, we must use a research approach that is consistent with our ecological theoretical perspective (O'Brien, 2005); that is, a multidisciplinary approach that emphasizes process, outcomes, and context. Testing trends and predictors of physical and mental health requires that we accurately measure the health outcomes and the individual, family, community, and policy influences. Accurate quantitative measures are available to measure some variables (e.g., physical and mental health, regional unemployment, family income), but in order to achieve a contextualized in-depth picture of each family we also need rich qualitative data about each family. Qualitative techniques for interviewing and developing case descriptions (Creswell, 2008; Yin, 2003) can provide these details. By combining the complementary perspectives of the quantitative and qualitative datasets, a mixed methods approach permits a more complete understanding of the interactions between context and health outcomes (Creswell & Plano Clark, 2007; Greene & Caracelli, 1997; Tashakkori & Teddlie, 2003). Many important contextual and health variables are known and will be measured in order to test relationships. However, our design also needs to be consistent with understanding the contexts of health outcomes. We recognize that some important variables may be currently unknown and that each family's context is unique; we cannot know in advance which variables are more salient, especially for minority families. The data collection, therefore, will include a rigorous qualitative component to capture individual families' perspective and context in order to develop a more complete systemic picture of the interactions and influences on health outcomes over time.
The research team has a history of using their complementary strengths to develop research questions, design, and conduct quantitative and qualitative analyses to produce a more holistic study. To date, the research team has spanned distance and time by using such technologies as sharing of data files using a File Transfer Protocol (FTP) site, a website, audio-conference calls and annual on-site meetings, and Macromedia Breeze as a dissemination system. The current team members are uniquely positioned to build upon the current infrastructure and begin a new multistate project. Advantages of a Multistate Effort
A multistate approach to studying the health of diverse rural low-income families has many advantages and each state offers a unique setting. The study of many states representing different geographic regions allows for a comparison of contextual factors such as access to health care, seasonally available food, emphasis and opportunities for recreation, tobacco use, and economic well-being. The study of several states provides a deeper understanding of how these factors act and interact to influence outcomes. Each state is also characterized by a different population profile. Race/ethnicity, immigration status, age of population, and acculturation are all important to health outcomes. Comparison of these diverse populations from several states will enhance our understanding of how these factors influence health in rural low-income families. A multistate approach will also provide a valuable opportunity to study the effect of policy on families' health. Policy varies both between and within states; this variation is essential to the study of interactions between policy and other contexts for health. No one state can capture the diversity of a national sample; a multistate approach provides a cost-effective alternative to a national rural sample by capturing variation in factors that influence the health of rural families. Additionally, the use of a common protocol for both the quantitative and qualitative components allows the development of a rich multistate dataset.
This project will be uniquely positioned to increase understanding around health in rural America. This study will add to the body of knowledge regarding the well-being of rural communities and diverse rural low-income families. A better understanding of rural family health can lead to better quality of life and therefore sustainable rural communities. Families who are not healthy are not able to contribute to their communities, socially or economically. The study will provide data for customizing programs and public policy to meet the needs of rural America. It also will expand the capacity of the land-grant system to educate and train graduate student researchers; enrich the curricula of courses in sociology, economics, family studies, nutrition and health; inform the programming that Cooperative Extension offers to families and communities across each state; and extend expertise of the system to citizens in support of the prosperity of rural America. This project can have both regional and national impacts because there are multiple layers of data collection (i.e., community, regional and national level).
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