NC_old1171: Interactions of individual, family, community, and policy contexts on the mental and physical health of diverse rural low-income families

(Multistate Research Project)

Status: Inactive/Terminating

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Rural communities and families continue to experience health inequalities when compared to their urban and suburban counterparts. In fact, several measures (deaths related to cancer and hospital admission with pneumonia, as well as rates of obesity) indicate an increase in rural health disparities despite efforts to improve health care quality, access, and affordability among rural areas (AHRQ, 2012). Further, emerging research indicates that rural female mortality rates continue to rise despite an increase in medical care expenditures and public health efforts (Kindig & Cheng, 2013). In order to fully understand and effectively address rural health disparities, research and interventions are needed that examine how various system components (i.e., individual, family, community) and policy interrelate and influence the health and well-being among rural communities and families. This is especially critical given the continued changing socio-demographics of rural America and recent federal health care legislation (i.e., Affordable Care Act). Yet, there is a dearth of data on rural family health, especially data related to the health of diverse rural low-income families and the community and policy contexts they experience that shape their health and well-being.

Residents of rural areas have unique issues and needs, including distinct health concerns. These health concerns are associated with multiple factors, including growing concentrated poverty in rural America, as well as an increase of racial/minority families in rural America who are at greater risk for health disparities. The poverty rate in rural America was 16.5% in 2006-2010 compared to 14.8% in 2000. Hispanics and African Americans are the largest minority groups in rural America (9.3%, 8.2% respectively). Additionally, more than half of the rural population growth over the last decade was due to increase in the Hispanic population (Housing Assistance Council, 2012). While concentrated poverty has historically been associated with the rural South, today it has spread to rural West and Midwest communities, partially due to the recent economic recession and slow recovery. Furthermore, the prevalence of high-poverty counties and the proportion of the poverty population residing in high-poverty counties have been higher in rural areas than in urban areas. In 2006-10, 26.2 % of rural counties were high poverty, and 36.1 % of the rural poverty population resided in high-poverty counties. Among urban counties, 10.3 % were high poverty in 2006-10, and 14.5% of the urban poverty population resided in those counties (Farrigan & Parker, 2012). Additionally, while overall in the U.S., unemployment rates in rural areas are similar to rates in urban areas, employment growth rates over longer periods are higher in urban areas than in rural areas (Kusmin & Hertz, 2010).

Lower household incomes and higher poverty rates in rural communities compared to urban communities are associated with greater levels of adult (McLaren, 2007) and child obesity (Grow, et al., 2010; Eagle, et al., 2012). Additionally, death rates for children and young adults are higher in rural counties, and rural residents have a higher incidence of certain types of heart disease, have more activity limitations due to chronic health problems, and a higher suicide rate. Lack of health care providers, especially dentists and mental health providers, and lower incidence of health insurance coverage, additionally contribute to poorer health outcomes for rural residents (Eberhardt, Ingram, & Makuc, et al., 2001; HHS Rural Task Force, 2002).

Studies reveal that the health and well-being of families living in high-poverty areas is undermined by a lack of access to mainstream social and economic opportunities. For example, children who grow up in high-poverty neighborhoods are less likely to succeed academically, complete high school, or attend college than those who grow up elsewhere. Additionally, rural racial/ethnic minorities commonly reside more often in high poverty communities than their urban counterparts; thus they are more likely to experience many of the problems and limitations associated with urban poverty, even if they are not poor themselves. Among those who are poor, they have fewer options to live elsewhere. Rural immigrants who have less than a high school education or who are female heads of families with children are at high risk. Their urban counterparts are less likely to be at risk as they are less likely to reside in high-poverty counties (Farrigan & Parker, 2012).

To improve health, especially among low-income populations, multiple factors, including social factors (e.g., inadequate housing, unemployment or under employment, low income, low education, inadequate access to healthy food and transportation) need to be addressed. Studies have revealed that social factors play a greater role in determining peoples life expectancy than health care, and have been linked to more frequent emergency room visits, hospitalizations and overall poorer health, all of which place strain on the U.S. health care system (Goldstein & Holmes, 2011).

The ecological systems perspective (Bronfenbrenner, 1979) provides theoretical framework for this project. 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. The influence of individual systems may also change over time. For instance, the cultural context (i.e. macrosystem) in which individuals live evolves over time as cultural norms shift and evolve. Likewise, the patterning of environmental events and transitions over the life course (i.e. chronosystem) impacts the developmental course of individuals and systems. Most research on families focuses on only one system level without consideration of interactions among the levels or changes over time, but research generated from NC1171 and NC223/NC1011 has demonstrated that multiple contexts influence individual and family well-being. This project is in a unique position to enable examination across all of the system levels and over time to determine impacts on the physical and mental health outcomes of individuals living in rural low-income families.

Technical Feasibility
Most rural data are collected from communities whose populations are 50,000 or more residents. This proposed project will contribute findings and dissemination products that will advance the understanding of multiple factors that influence the health of low-income families living in small rural communities (UIC of 5 or higher), and contribute to the development of opportunities to address long-standing health challenges in rural communities.

Quantitative and qualitative data related to child and family health in the NC1171 data set are very rich. Quantitative data (e.g., BMI, maternal depression, household food security, child internal and external behaviors, financial stress) collected during wave 1 (N=444) will be complemented with qualitative data (e.g., changes in health, barriers and enablers to health) collected during wave 2 (N=80) to examine individual, family, and community level factors and policies that influence rural family health. The qualitative data captures families' perspectives and contexts and will assist in developing a more complete systemic picture of the interactions and influences on health outcomes over time. An emergent approach to the qualitative data will be used allowing previously unidentified variables of importance to emerge in order to capture potentially new and critical constructs of interest. Additionally, a third wave of quantitative data collected during 2013-2014 will provide opportunity to compare baseline (wave 1) data to data collected over time (wave 2, wave 3) to identify trends and relationships among factors influencing individual and family health.

Furthermore, the 2010 U.S. Census and American Community Survey data will be matched with the NC1171 family level data in order to compare demographics of study families with other families in the study communities. Additionally, participants addresses will be matched with data provided in the USDA food environment atlas (http://www.ers.usda.gov/data-products/food-environment- atlas.aspx#.UhP9bj-Dkyk) in order to identify and analyze relationships, patterns, and trends between factors such as where participants live and the local food environment. Additionally qualitative data collected during wave 2 will provide additional insight into why participants do or do not access food and health resources in the community.

This multi-state research team has been in existence since 1998 (NC223, NC1011, NC1171) and has a history of using their complementary strengths to develop research questions, design, and conduct quantitative and qualitative analyses to produce holistic studies. In addition to members who serve as senior faculty and Extension specialists at their institutions, several team members began their work with the project as graduate students, and now are junior faculty members at different institutions. The team has spanned distance and time by using technologies to communicate and share data files via a SharePoint site, a Web site, conference calls, annual on-site meetings, and Adobe Connect. The projects governance document is annually updated, and a tracking tool is put in place via SharePoint to facilitate collaboration among team members in regard to developing presentations, policy briefs, manuscripts and other products. Team members are positioned to build upon the existing infrastructure and begin a new multi-state project.

Advantages of working as a multi-state effort

This project extends and builds upon a longstanding multi-state, multidisciplinary effort consisting of family scientists, family economists, nutritional scientists, social workers, extension specialists, psychologists, and sociologists. Furthermore, this multi-state, multidisciplinary project seeks to promote a larger scope of understanding of the contextual factors that influence the health and well-being of rural low-income families. The study of many states representing different geographic regions allows for a comparison of contextual factors such as access to health care and food, and emphasis and opportunities for recreation, tobacco use, etc. The study of several states provides a deeper understanding of how these factors act and interact to influence health outcomes. Each state is also characterized by a different population profile. Race/ethnicity, immigration status, 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 multi-state 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 multi-state 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 multi-state dataset.

This fruition of this understanding lies in the analyses of the substantial data set collected during NC1171, and the subsequent dissemination of findings. It is expected that this project will create a unique lens for understanding rural poverty, culture, and ultimately the social determinants of health and well-being. Thus, a deeper understanding will inform policy, pedagogy, and practice. Expected Impacts

This project is uniquely positioned to contribute to and enrich the body of knowledge regarding the health of low-income families in rural America. Through a multidisciplinary approach, a framework focused on improving the health of rural families will center on the strengths and challenges rural families face in obtaining optimal physical and mental health. It is anticipated that this framework will allow researchers, extension and other educators, and community stakeholders to further develop research agendas, as well as create products (e.g., curricula, programs, policy briefs) that recognize the unique context and needs of rural America and would specifically address current challenges and barriers low-income rural families face in achieving optimal health. Dissemination products will focus on multiple factors that influence health outcomes, including social factors (e.g., inadequate housing, unemployment or under employment, low income, low education, inadequate access to healthy food and transportation).

Involving project members representing a variety of disciplines and position responsibilities (e.g., teaching, extension/outreach, research) in developing and implementing the dissemination plan will expand the capacity of the land-grant system to educate and train graduate students; enrich the curricula of courses in sociology, economics, human development and family studies, nutrition and health; inform Cooperative Extension programming; and further extend expertise of the land grant system to support prosperity in rural America. This project will lead to impacts at multiple levels (i.e., family, community, state, national).

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