Health Disparities

addressing rural issues

1. Increasing health literacy through school, doctor's appointments, etc 2. Increasing accessibility to health care Increase insurance to those in rural areas

Access to insurance

7.9% of children in rural America do not have insurance, compared to 6.2% in urban/suburban settings Those who are uninsured are 3 times more likely to not go to the doctor when they feel sick

Vaccination Rates HA

overall rates are lower for adult population due to social determinants of health already discussed -flu vaccine rates vary for adults depending on where they live -child immunization rates however are consistent due to assistance programs

Basic Rural population facts

1. 15% of all americans live in rural areas 2. Only 9% of physicians work in rural areas 3. Nine US states have more cows than people (SD, NE, MT are top 3)

Agencies & Organizations working to seek solutions to these disparities

1. Federal Office of Rural Health Policy (FORHP) 2. Agency for Healthcare Research and Quality (AHRQ) 3. National Institute on Minority Health and Health Disparities (NIMHD) 4. National Rural Health Association (NRHA) 5. Robert Wood Johnson Foundation (RWJF) 6. Rural Health Research Centers 7. National Cancer Institute Center to Reduce Cancer Health Disparities (CRCHD)

social determinants of health

1. Economic Stability 2. Social and Community Context 3. Neighborhood & Enviro 4. Health Care 5. Education

Health literacy rural

1. Literacy in general is also lower in rural areas 2. Lower health literacy scores in rural areas can essentially be explained by differences in age, gender, race, ethnicity, education, and income.

Social factors and risks affect AA at younger ages

1. unemployment 2. living in poverty 3. no home ownership 4. Cant see MD 5. Smoking 6. Not active 7. obesity

Mental Health rural

Mental Health ●Higher depression and suicide rates ●Less likely to seek care due to shame and stigma ●Less likely to be able to afford mental healthcare services ●Substance abuse ○Opiods- poor access to basic substance abuse tx, lack in edu, lack in emergency personnel, lack in access to resources (naloxone)

programs for rural

Rural Health Models and Innovations Hidalgo Medical Services - Family Support Program Kentucky Homeplace Health Extension Rural Offices (HEROs)

Poverty Rural

The poverty rate is consistently higher in rural areas. Average income is also lower in rural areas. The rural per capita income in 2018 was $49,867, compared to $63,179 for the nation as a whole.

Access to meds

There are 65 primary care physicians per 100,000 rural Americans, compared to 105 primary care physicians for urban and suburban Americans. Rural Americans are at higher risk for chronic health conditions with lower access to specialties for these conditions

Rural Activity level

While they are more likely to have physically demanding jobs, people in rural areas are more likely to be inactive during leisure time. They're also more likely to have activity limitations due to chronic health issues.

Use of staff cultural mediators in HA

○Assist patients by attending their medical appointments, visiting them in their homes, and connecting them with Primary Care Providers ○Work with hospitalized patients to make sure that patients understand their treatment ○Help with Patient Education ■REACH (Racial and Ethnic Approaches to Community Health) ●Program funded through the CDC ■Dr. Francisco Garcia worked with the medical professionals and the Mexican-American community in Tucson AZ ●Came up with a Cervical Cancer curriculum ●Trained other women (promotores) to teach community about cervical cancer risk and the importance of screening

provider advocacy general AA

○Attend cultural competency training ○Identify one's own bias ○Work to build trust with patients ■Ask about and address barriers to care ○Be aware of/involved in local policy

Eating habits hispanics

○Breakfast consists of more carbs and eggs ○Often eat more rice and grains compared to other groups (tacos, tortillas, rice) ○Portion sizes are often larger than that of what's expected ○Those who come from poverty in their own country see underweight as dangerous or an illness, but see overweight as wealthy

Factors identified tht contribute to rural obesity

○Influence of poverty ○Limited access to healthy and affordable food ○Higher calorie consumption ○Lack of nutrition education and services ○Limited access to obesity prevention programs and weight management services ○Fewer opportunities for children to be physically active in afterschool sports or events ○Scarcity of parks, recreational areas, sidewalks, bike trails, and exercise facilities that promote physical activity ○Reliance on automobiles to meet transportation needs, rather than walking or biking

provider advocacy edu aa

○Provide relevant education to your African American patients ■Address higher risk diseases and diagnosis

Rural DM

●"Diabetes Belt" ●Risk factors: obesity, sedentary lifestyle, extreme poverty, food insecurity, significant unemployment rates ●Genetic / racial component - African and Hispanic descent, Alaskan Natives, American Indians ●Lack of education

Health Behaviors of Rural populations

●A CDC report found that only 1 in 4 rural adults practices at least 4 of 5 health-related behaviors that can prevent chronic disease: ○Not smoking ○Maintaining a normal body weight ○Being physically active ○Not drinking alcohol or drinking in moderation ○Getting sufficient sleep ●Whereas, about ⅓ of U.S. adults practice at least 4 of the 5 behaviors.

Health Risks Covid 19

●Affecting African American communities more seriously than white communities ●In Louisiana African Americans account for 33% of the population but 70% of the deaths

Health risks: Heart health aa

●African Americans ages 18-49 are 2x as likely to die from heart disease. ●African Americans ages 35-64 years are 50% more likely to have HTN. ●The prevalence of hypertension in African-Americans is the highest in the world ○This increased risk of heart disease, stroke, and many other potential risks ○HTN is usually more severe in this population and often develops earlier in life

SDH: AA Healthcare

●African Americans remained 1.5 times more likely to be uninsured than Whites ●9.9 percent of non-Hispanic African Americans are uninsured ●Less access to healthcare in general

Social Determinants of Health Affecting Rural Populations

●Availability of resources to meet daily needs (e.g., safe housing and local food markets) ●Access to educational, economic, and job opportunities ●Access to health care services ●Quality of education and job training/Literacy ●Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities ●Transportation options ●Social norms and attitudes (e.g. distrust of government, distrust of medicine)

Health Risks Common Comorbidities

●Chronic liver disease is a leading cause of death due to chronic alcoholism, obesity, and exposure to Hep B and C ●African American adults are 60% more likely to be diagnosed with diabetes than non-hispanic whites, and twice as likely to die from it ●African Americans are 20% more likely to die from heart disease than non-hispanic whites

Provider advocacy AA community outreach

●Community Outreach ○Provide education and resources to areas patient may be more likely to seek care ■Places of worship, recreation centers, after school programs ○Consider attending career days at local schools ■Provide education on importance of healthcare ■Increase diversity of healthcare workforce/encourage further education ○Volunteer at health fairs

Health Behaviors: exercise hispanics

●Exercise habits ○Lower prevalence of exercise (~40%) as compared to non-hispanic counterparts (~50%) despite stronger support system ○Often attributed to lack of available resources and financial means

health behaviors: healers, HA

●Formal Healers ○Doctors, nurses, etc. ●Spiritual/Traditional healers ○Curanderismo ○Espiritismo ○Santeria ○Yerbista ○Sobador ●"Hot" and "Cold" illnesses ○Cold: cancer, colic, indigestion, headache, menstrual cramps ○Hot: anger, diabetes, diaper rash, hypertension, pregnancy ●Healing elements ○Food, teas, poison ○Holy water, religious rituals, promises

Health Behaviors: AA substance use

●Have a lower rate of successful tobacco cessation than other demographics ●Highest reported rate of using tobacco as a tool to handle stress (perceived ethnic harassment) ●Highest percentage of deaths from alcohol-related injuries

Health Risks: Hispanic

●Heart disease ●Cancer ●Unintentional injuries (accidents) ●Stroke (most likely to have uncontrolled HTN) ●Diabetes ●Some other health conditions and risk factors that significantly affect Hispanics: ○Asthma (2x likely to present to ED for asthma) ○Chronic obstructive pulmonary disease ○HIV/AIDS (25% of all cases in 2016) ○Obesity ○Suicide (2017 2nd leading cause of death) ○Liver disease ●Higher risk of obesity (78% of hispanic obese vs. 64% non-white hispanic) ●Risks among sub groups: ○Low birth weight in Puerto Ricans (almost 2x non-hispanic whites) ○Puerto Ricans also have higher incidence of asthma, HIV, and infant mortality ○Mexican Americans larger incidence of diabetes

Rural stroke

●Higher mortality rates in rural areas ●Greatest risk factor is hypertension ●Acute stroke management

Sexual history rural

●Higher rates of STIs ●Lack of screening, preventative care, patient education, and treatment ●Prevailing stigma and conservative belief system hinder search for health care ●Less tolerant to LGBTQ individuals ●~27% of rural residents are HIV positive ●Most affected groups are black and Hispanic individuals between 25-44 yrs

Health risks: Cancer AA

●Highest cancer rates compared to other populations include colon, prostate, stomach, and breast ●African Americans have the highest mortality rate of any racial and ethnic group for all cancers combined and for most major cancers ○Usually due to late diagnosis and decreased likelihood of receiving surgery.

Health risks: respiratory

●In 2018 the prevalence of asthma amongst African American and black individuals was 10.6% compared to 7.6% for whites individuals ●In 2015, 2.6 million African Americans reported that they currently have asthma ●Black children have a 500% higher death rate from asthma compared with white children

how to address lack of insurance in rural

●Increase Medicaid expansion ●Single payer healthcare

How to address the issues of access

●Increase access to telemedicine ○Further trouble here, access to computers/internet: 1/4th of the rural population lacks internet access ●Increase PCP in rural areas ○Easier said than done, many programs offer loan repayment to go to rural areas and there is still a shortage

second hand smoke rural

●Influence of tobacco industry ○Youth in rural areas are less likely to be exposed to anti-tobacco messages in the media, and begin smoking earlier in life. ●Smokers who live in rural areas are less likely to have access to programs that help them quit smoking.

Health behaviors AA preventative care

●Less likely to seek preventative care ●African American adults are less likely than other populations to have received the flu vaccine in the past year or to have ever received the pneumonia vaccine ●African American women are 10 percent less likely to have received an HPV vaccine as white women ●Adolescent African Americans are significantly less likely to have been fully immunized

Rural lung cancer

●Less patient education ●Less screening

Further SD: Hispanic

●Level of unemployment is higher among Hispanics than non-Hispanic Whites ●Highest likelihood of working in a high risk occupation (increased injury and infection rates) ●Level of poverty ~18% Hispanic/~17% Mexican American (Non-hispanic white ~8%) ●More likely to live near a major highway, increasing exposure to traffic related air pollution ●Highest percent of of adults not completing high school ○~68% of Hispanics have high school diploma vs ~92% non-Hispanic White ●Adolescent birth rates are 2x higher than caucasians ●Stereotyping and cultural/racial biases

Rural Breast cancer

●Limited access to screening ●Long distance travel ●More likely to be diagnosed at a later stage ●Higher risk of complications due to older ages and comorbidities

Health risks: HIV aa

●Make up 13% of the US pop but account for 44% of HIV infection cases in 2016 ●Males have 8.6 times the AIDS rate as white males, and females have 18.6 times the AIDS rate ●In 2016, African Americans were 8.4 times more likely to be diagnosed with an HIV infection than the white population and had a much higher death rate

Access to resources rural community

●Many rural areas lack places to buy food and are considered food deserts ●In 2012, 16.7% of nonmetropolitan residents participated in SNAP compared to 12.8% in metropolitan areas ●They may also live further away from other important services such as education, employment, recreation centers, and polling places ●They face danger trying to get where they're going - in 2012 54% of road fatalities occurred in rural areas

SDH: Economic AA

●Median income for an African American household is $42k versus whites, which is $71k. Asian households average income is the highest at $87k. ●Among racial and ethnic groups, African Americans had the highest poverty rate, 27.4 percent, followed by Hispanics at 26.6 percent and whites at 9.9 percent.

Hispanic Social determinants

●More likely to be uninsured than any other racial/ethnic groups (31-34% are uninsured) ○Lower access to preventative care ○Immigrants don't qualify for insurance ●Stigma around immigration status ○Behavioral problems rooted in stress related to immigration status/trauma from their own country ■Family Splitting ■Trauma linked to gang recruitment ●Hispanic adults have the lowest average health literacy compared to any other racial/ethnic groups ●Language barrier

Health risks: maternal and infant care AA

●Mothers were 2.3 times more likely to receive late or no prenatal care ●Black women were 3.3 times more likely than white women to suffer a pregnancy-related death ●2.3 times the infant mortality rate as non-hispanic whites ●Over twice SIDS mortality rate as non-hispanic whites in 2017 ●This is something that holds true across educational levels and socioeconomic status

SDH: AA edu

●Nationwide high school graduation rates, black students graduated at a rate of 69 percent; Hispanics graduated at 73 percent; whites graduated at a rate of 86 percent. ●White and Asian students completed their programs at similar rates -- 62 percent and 63.2 percent, respectively -- while Hispanic and black students graduated at rates of 45.8 percent and 38 percent, respectively

Obesity of rural

●Obesity and overweight are ongoing health concerns nationwide. ●Rural areas experience higher rates of obesity and overweight than the nation as a whole, yet many rural communities don't have the resources to address these health concerns

Health Behaviors: AA physical Activity

●One of the lowest reports of physical activity in United States groups ●In 2018, this group was 20% less likely to engage in PE than non-hispanic whites ●African American women have the highest rates of obesity than any other US group (4 out of 5 are overweight or obese) ●African Americans are 1.3x more likely to be obese than non-hispanic whites ●High levels of weight-related comorbidities such as blood pressure, blood fats, cholesterol and diabetes ●The incidence of hypertension is higher among african american patients than it is among the US in general; 44% vs 33%

SDH: AA neighborhood and environment

●Race is the best indicator of whether or not you live near pollution ●African Americans are 79 percent more likely than whites to live where industrial pollution pose the greatest health danger. ●More likely to seek places of worship for mental health than a provider. ●Transportation is often cited as a huge barrier to care.

rural CD

●Risk factors: Obesity, hypertension, diabetes, socioeconomic disadvantage, social and cultural issues ●More likely to have limited access to healthcare, healthy foods, and physical activity ●Women fare worse than men ●Racial minorities worse than whites

Address issues of rural: Health literacy

●Spot illiteracy to help patients before it becomes a severe issue ●Use pictures during explanations ●If low literacy and english is their second language ○Ask if they prefer another language and use a translator ●Increase information in health class K-12.

Social Determinants Impact of Small Community

●The effect of a small community ○High potential for provider patient interaction outside of office ○Less likely to seek mental health care- social stigma, lack of privacy ○Poor provider-patient relationship- not easy to find a new PCP

Smoking in rural areas

●The prevalence of cigarette smoking among U.S adults is highest among those living in rural areas (28.5%) and urban areas (25.1%) and lowest among those in small and large metropolitan areas. ●The health of rural areas is impacted more so due to socioeconomic factors, culture, policies, and lack of proper healthcare. ●18-20% higher rates of lung cancer than people living in urban areas

Health Behaviors: psych distress

●Twice as likely to report psychological distress due to low poverty level ●Suicide is the second leading cause of death for ages 15-24 ●High school aged females were 60% more likely to attempt suicide than non-hispanic whites in 2017

Rural Prostate cancer

●Undertreated for prostate cancer - particularly for black men ●Less patient education

Prenatal/ob Health

●Up to 40% of all US counties (mostly rural) lack an obstetrician, midwife, or family physician attending births ●Most women in rural areas rely on PCPs for all their maternal health ●More likely to seek prenatal care later in pregnancy ●More likely to affect Alaskan Natives, American Indians, and non-Hispanic black women ●Increased risk of preterm birth, birth defects, low birth weight, maternal complications, injuries, SIDS, and infant mortality

Address issues of HA

●Use of translators ○Nearly ⅓ of Hispanic in the U.S. are not fluent in English ●Asking questions about cultural belief ○Salvadorian women follow the cultural practice of quarantine for 40 days after giving birth ●Assessing Health Literacy ○Use techniques like teach-back ●Social Workers ○Many are bilingual ○Offer short-term therapy focused on remediating symptoms and coping strategies ■Most patients only come once or twice

Provider advocacy: AA

●Use proven programs to reduce disparities and barriers to create opportunities for health. ●Work with other sectors, such as faith and community organizations, education, business, transportation, and housing, to create social and economic conditions that promote health starting in childhood. ●Link more people to doctors, nurses, or community health centers to encourage regular and follow-up medical visits. ●Develop and provide trainings for healthcare professionals to understand cultural differences in how patients interact with providers and the healthcare system.