Rural Communities and Western Maryland

What is rural?

What issues impact health and health care in rural communities?

• The Rural Economy
• Educational Disadvantage
• Cultural Factors 
• Access to Health Care
• Health Status
• Scarcity of Health Professionals
• Special Populations and Issues

Why is Western Maryland considered rural and what are its health issues?

• Definition
• Economy
• Educational Disadvantage
• Cultural Factors 
• Access to Health Care
• Health Status 
• Scarcity of Health Professionals
• Special Populations and Issues

What is rural?*

• low population size and density,
• distance from urban areas,
• low degree of urbanization,
• types of economic activity.

• Towns with population of 2500 or less
• Areas of open country- accounts for 23% of US population

The Office of Management and Budget (OMB) defines rural by exclusion:

• Any area outside of a Metropolitan Statistical Area (MSA)

Economists/Geographers as a group suggest the following:

• Small scale, low-density settlements
• Distant from large urban centers
• Reflects rural economies

Rural includes frontier areas in the west, midwest farmlands, and geographically isolated small communities in the east.

• Ethnicity- Includes African American, Native American, Hispanic, immigrants
• Culture- Any group with a set of beliefs, norms, customs and rituals, such as Appalachian, Amish
• Economy- Includes farming, ranching, mining, recreation, tourism, logging, mills and specialized manufacturing
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"When you've seen one rural community, you've seen one rural community." (Hunter ...

What issues impact health and health care in rural communities?*

• Factory closings, farms sold--> young and middle-aged adults leave or commute great distances for jobs. Smaller tax base might not be able to support needed services.
• A greater percentage of rural families live below the poverty level.
• Poverty leads to...
  • Substandard housing,
• Lack of transportation,
• Limited resources to buy healthy food, medicine, or health insurance,
• Poorer health status,
• Lack of resources and time for physical and other health maintenance and prevention activities,
• Restricted opportunity for a better life.

• Limited funding, inadequate facilities, low teacher salaries.
• Larger portion of the population is aging and has less formal education than the national average.
• Fewer high skilled, high paying jobs. Youth may opt for early parenthood or unskilled jobs.
• May lack knowledge regarding healthy options and disease prevention.

• Strong people orientation- face-to-face interaction preference.
• Traditional values- tend to be more politically and socially conservative.
• Suspicion of outsiders.
• Connection to the land- hunting, fishing, growing...being outside.

• Geography - distance, hazardous terrain and weather
• Transportation - public system not convenient, limited routes and schedules
• Lack health insurance - not offered by employer, not affordable, self-employed

• According to the Healthy People 2010, "People living in rural areas are less likely to use preventive screening services, exercise regularly, or wear seatbelts...Timely access to emergency services and the availability of specialty care are other issues for this population group" (p. 16).
• There is a higher incidence of some chronic diseases such as cancer, cardiovascular disease, and chronic respiratory disease- often region specific.
• There may be a lower mortality rate (4 percent less than the national average) except regarding infant mortality, and those related to automobile accidents, agriculture and mining.

• Health Professional Shortage Area (HPSA)
  • In 1996, nearly two-thirds of the nation's rural counties were HPSAs.
• Medically Underserved Area (MUA) or Medically Underserved Population (MUP)

Migrant and Seasonal Farmworkers

• This group is typically isolated from the larger community, often speaks limited English, lives in poverty and substandard housing. They often lack health insurance and do work which exposes them to chemicals and dangerous equipment.

Children and Family Health

• Limited access to health services due to geographic isolation, combined with high poverty rates in rural areas, create problems particularly in getting prenatal and obstetrical care and well-baby care. Some rural subgroups have high infant mortality rates. Rural children are at increased risk for parasitic and infectious diseases as well as farm injuries and motor vehicle accidents. They are less likely to see primary care physicians and dentists and need to travel further for specialty care. Poor rural children have more developmental disabilities and speech, vision and hearing impairments than other children.
• Rural adolescents now equal or exceed their urban counterparts in the use of illegal drugs. Frequent alcohol use is linked to auto accidents and violence, especially among young males. Teen pregnancy is also a problem.

Occupational Health

• There is often an increased risk of exposure to dangerous substances or injury via occupations such as farming, mining and logging. Farmers risk injury due to working with machinery, animals, chemicals, and from working long hard hours in all kinds of weather. The inexperienced young or aged farmer is at highest risk. Timber workers experience twice as many illnesses and injuries as industrial workers.

Mental Health Issues

• Rural areas, like elsewhere, have individuals with mental illness and psychosocial problems. Isolation can lead to feelings of depression, particularly among the elderly. According to Hunter, et al, "psychological dysfunction and suicide have occurred among members of farm families in increasing numbers as a result of insurmountable financial problems that may cost them not only their homes and livelihoods, but their entire way of life." Poverty stressors and other cultural factors may lead to domestic violence and substance abuse, resulting in increased deaths, emergency room visits and hospital admissions.

Older Adults in Rural Areas

• The elderly are the fastest growing segment of the population and often face high rates of chronic illness and risk of disability. The health care team needs to focus on helping them maintain health and independence and delay disability. Service gaps and lack of resources plague the rural elderly.

Chronic and Disabling Conditions

• There is a significant burden of chronic illness in rural areas. Arthritis, diabetes, COPD, hypertension and renal disease are prevalent. Rural residents suffer chronic diseases and disabilities at younger ages than their urban counterparts. A life of hard labor or unfavorable work conditions intensifies the problem. Ethnicity can also be a contributing factor such as the high prevalence of diabetes among some Native Americans.

 

• Since 1980, many of the manufacturers located in Allegany and Garrett counties have closed, leaving high unemployment. Manufacturers that shut down included Kelly Springfield Tire Company, Celanese, Pittsburgh Plate Glass, and Bausch and Lomb.
• Farming is a significant part of the Garrett and Washington county economies.
• All three counties are looking more to tourism and the service industry for jobs. Washington County has four state and federal prisons and Allegany County has two prisons built in the 1990s. Garrett County has a resort industry centered on Deep Creek Lake, the Wisp Ski Resort and Golf Course, and its three state parks.
• Allegany County has a trend of declining population and out-migration over the past several decades. In the 2000 Census, there was less than a 1 percent population increase since 1990, actually due to the inclusion of the prison population in the count for the first time.
• In December 2001, the Maryland Department of Economic Development reported Maryland's unemployment rate as 3.9 percent. In contrast, Allegany County's rate was 7.8 percent, and Garrett County's 8.5 percent.

• According to the 2000 Census Report, Maryland's per capita income in 1999 was $33, 872; however, Allegany County's was only $21, 453; Garrett County's was $19,360; and Washington County's was $24,162.
• Maryland's rate of children living in poverty was 12.9 percent in 1996; Allegany County's rate of 25 percent was nearly double the state average; Garrett County's rate was 22.1 percent; and Washington County's was 14.3 percent (Data from the 2000 Maryland KidsCount Factbook).
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• The percentage of college graduates age 25 and over in the three counties is about half the state rate or less: 15.6 % in Maryland, whereas only 7 % in Washington County, 7.8% in Allegany County and 5.7% in Garrett County (1990 U.S. Census).
• In 2001, more than 60 percent of all students who attended one local community college were the first in their family to attend college (Department of Institutional Research, Allegany College of Maryland).
• Persons 65 years and older represent 18 percent of residents in Allegany County, 15 percent in Garrett County and 14 percent in Washington County compared to an 11 percent state rate for that age group.
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• An Appalachian heritage fosters a sense of pride and self-sufficiency among Western Maryland residents. With the exodus of jobs and workers, and the remaining population of young and old, many residents may not receive the full benefit of the services for which they qualify.
• All three westernmost counties are considered to be conservative.
• Amish and Mennonite communities exist in Garrett County.
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• The region's percentage of uninsured for 1998 was 15.3 percent, compared to 13.8 percent for Maryland as a whole (State Health Care Expenditures: Experience from 1998, Maryland Health Care Commission). The Commission includes Frederick County in this total, which is located closer to metropolitan areas. The rate in the far western counties is significantly higher.
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• Measures of health status indicate that residents of Western Maryland have a larger percentage of unmarried mothers, a higher neonatal mortality rate, and higher incidences of breast, colon, and lung cancer as well as more coronary heart disease than does the United States as a whole (Community Health Status Report, 7/2000).
• Allegany County leads the state in deaths from heart disease, stroke, and chronic pulmonary disease (State Health Care Expenditures: Experience from 1998, Maryland Health Care Commission) and Garrett County is close behind.
• For detailed information by county, access the Community Health Status Reports, July 2000, online at http://www.phf.org/data-infra.htm. Type in the state and county whose profile you wish to see.
• To view the Health Improvement Plan, July 2001, for each Maryland county, visit http://mdpublichealth.org/ohp/html/hip.html.
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• Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA) designations in Western Maryland as of December 2001:

Dental HPSA

Primary Care HPSA

MUA- entire county

MUA- east part of county (Orleans, Oldtown) and much of Cumberland

Dental HPSA- entire county

MUA- western portion (Clear Spring, Hancock, Indian Spring), southern area (Rohrersville, Keedysville, Sandy Hook) and downtown Hagerstown

• Migrant Workers - Washington County and its neighboring Pennsylvania and Virginia counties use seasonal workers, particularly in the orchards.

• Children and Families - Western Maryland has a higher neonatal mortality rate than the state average rate. In Garrett County, there are no obstetricians and the family practitioners handle most pregnancies. At-risk mothers and newborns are sent to Morgantown West Virginia or elsewhere outside of Western Maryland for specialized care. There are no pediatric cancer services, nor residential treatment centers for mentally ill children, although there is a psychiatric unit for adolescent substance abusers. There is a tremendous need for pediatric dental services, particularly for low income families. Allegany County has the worst dental health statistics in the state for its children. In 2001, fluoride was first introduced into the Cumberland and Frostburg public drinking water in Allegany County after being approved for two communities in Garrett County in 2000.

• Occupational Health - Both Allegany and Garrett counties were big deep-coal mining areas through the 1950s and surface mining continues today. Prevention of farm injuries is a major concern, particularly in Garrett County. A paper mill bordering Allegany County is one of the few remaining manufacturers, however past chemical and tire manufacturers exposed today's older residents to a variety of toxic substances which impact their current health.

• Mental Health Issues - Although a few state residential psychiatric facilities exist in Washington and Allegany counties, there are none in Garrett County and it is difficult to recruit sufficient psychiatrists to live and practice in the region. Several non-profit and private providers support individuals living in the community, but a full complement of services is often lacking. Poverty levels are high, increasing stress. Incidents of domestic violence, sometimes resulting in death, are frequently reported in the Cumberland Times News.

• Older Adults - The percentages of elderly in each of the three westernmost counties is higher than the state rate. Limited transportation options and mostly centralized services make it difficult to access care from outlying communities.

• Chronic and Disabling Conditions - Specialized services such as kidney dialysis, are concentrated in Cumberland, serving Allegany and Garrett counties as well as neighboring Pennsylvania and West Virginia communities. In Washington County such services are located in Hagerstown.