Economy, Access and Public Services
Health and Disease
Workforce, Infrastructure and Technology
Research & Scholarly Articles

Economy, Access and Public Services:

Inadequate Housing May Contribute to Poor Health in Immigrant Farmworker Families
Julie Early, M.S., Sara A. Quandt, Ph.D., Stephen W. Davis, M.A., Pamela Rao Ph.D., and Beverly M. Snively, Ph.D.
April 2006

Many Hispanic farmworker families in North Carolina live in inadequate housing that puts them at higher risk of exposure to disease, toxins and overcrowding that can affect their psychological well-being, according to new research by Wake Forest University School of Medicine.

To view full article, visit: http://www1.wfubmc.edu/News/NewsARticle.htm?ArticleID=1824.

Sheps Center Study Examines Effects of Rural Hospital Closures on Per Capita Income
Holmes, George M.; Slifkin, Rebecca T.; Randolph, Randy K.; Poley, Stephanie
April 2006

A study conducted at the University of North Carolina at Chapel Hill has concluded that closing the only hospital in a rural community has a negative impact on the local economy: In the three-year period after a lone hospital closed, researchers found the communities’ local per capita income levels fell 4 percent.

To view full article, visit: http://www.unc.edu/news/archives/apr06/ruralhospital040606.htm.

CAH Participation in Hospital Compare and Initial Results
Casey, Michelle; Ira Moscovice
February 2006

This report examines the participation of Critical Access Hospitals (CAHs) in public reporting of quality measures in the Centers for Medicare and Medicaid Services (CMS) Hospital Compare database and presents the initial Hospital Compare results for CAHs and comparisons with other groups of hospitals.

To view full report, visit: http://www.flexmonitoring.org/documents/BriefingPaper9_HospitalCompare.pdf.

Enrollment and Retention Patterns among Healthy Family Participants in Mendocino County
Kelsch, Christopher; Hausman, Jackie
December 2005

Mendocino County’s Children’s Health Initiative is working to provide health insurance coverage for every child in the County. As part of this effort, the County is seeking ways to improve enrollment and retention in existing public programs, and to design and implement a new insurance product for children ineligible for Medi-Cal and Healthy Families. In order to help Mendocino County in those efforts, the California Institute for Rural Studies has conducted an analysis of enrollment and retention patterns among Healthy Families participants in the County, based on a survey of 310 current and former Healthy Families participants and an analysis of administrative data from the Managed Risk Medical Insurance Board (MRMIB).

This study is part of the growing body of literature demonstrating that the provision of health insurance coverage to children is an effective means of improving access to care. The findings also supports the hypothesis that access to health insurance encourages parents to utilize preventive services for their children.

To view full report, visit: http://www.cirsinc.org/docs/Mendocino_Healthy_Families.pdf.

Can Money Buy Quality? Physician Response to Pay for Performance
Bodenheimer J., May H., Berenson R.A., and Coughlan J.
Issue Brief No. 102, December 2005

While pay for performance (P4P) has created a nationwide buzz among health plans, physicians and hospitals, most P4P initiatives are still on the drawing board, according to findings from the Center for Studying Health System Change’s (HSC) 2005 site visits to 12 nationally representative communities. HSC focused on performance-based payment for physicians, finding that only two HSC communities—Orange County, California, and Boston—have significant physician P4P programs. In the other 10 communities, where almost no physicians have received quality-related payments to date, physician attitudes about P4P ranged from skeptical to hostile. P4P, a concept best suited to larger physician groups, may be difficult to implement in markets dominated by small physician practices. In spite of substantial barriers to initiating performance-related payment for physicians, most large health plans and Medicare are planning P4P programs.

To view full article, visit: http://www.rwjf.org/files/research/Issue%20Brief%20No%20%20102%20FINAL.pdf.

Farm Poverty Lowest in U.S. History
Amber Waves: USDA Economic Research Service
September 2005

Poverty on America's farms has been an economic reality for most of the country's history. Fifty years ago, half of all farm families were poor. The images of impoverished farmers living through the Dust Bowl of the 1930s remain fixed in the minds of Americans. The New Deal, which was the genesis of many USDA programs, addressed the Nation's concerns for this vulnerable population, which, back then, relied largely on farming for its livelihood. Thus, safety net programs that linked payments to commodity production were a logical means of reducing farm poverty at that time.

Today, however, farm poverty is at its lowest level in the Nation's history, thanks to the availability of remunerative off-farm employment coupled with on-farm gains in labor productivity. The well-being of farm families, who are fewer in number than in the 1930s, has improved significantly and depends much less on the outcome of the farm business.
Still, some farmers remain poor—exactly how many depends on how poverty is defined. Closer examination of the statistical and demographic dimensions of farm poverty points to the questions that must be answered in order to devise a 21st-century approach to helping poorer farmers.

To read full article, visit: http://www.ers.usda.gov/AmberWaves/September05/Features/FarmPoverty.htm.

Medi-Cal Beneficiaries with Disabilities: Comparing Managed Care with Fee-for-Service Systems
California HealthCare Foundation
August 2005

As part of his efforts to close California's budget gap, Governor Schwarzenegger has proposed restructuring Medi-Cal, including for beneficiaries with disabilities. The plan would triple the number of disabled beneficiaries enrolled in managed care.
This issue brief synthesizes recent research about the experiences of non-elderly beneficiaries with disabilities in managed care and fee-for-service systems in California and other states. It is intended to help California policymakers understand and evaluate options for changing the delivery of and payment for services to Medi-Cal beneficiaries with disabilities.

Read full report at: http://www.chcf.org/topics/medi-cal/index.cfm?itemID=113383.

The Impact of Medicaid Cuts on Rural Communities
Pam Silberman, JD, DrPH, Matt Rudolf, BS, Laura Brogan, BS, Stephanie Poley, BS, Rebecca Slifkin, PhD, Charity Moore, PhD
August 2005

This study assesses the perception of state Medicaid staff and individuals from State Offices of Rural Health (SORH) and Rural Health Associations (RHA) regarding the impact on rural areas of state Medicaid policy changes that occurred between 2002 and 2004

Generally, because of Medicaid requirements, programmatic changes must be implemented consistently across the state; however, there are specific concerns for rural communities associated with Medicaid policy changes. Because a higher proportion of rural populations live in poverty and are elderly, they are more vulnerable to eligibility restrictions. Changes in reimbursement or benefits could create additional barriers to accessing care, because rural Medicaid beneficiaries already face greater transportation barriers and provider shortages. Finally, some rural providers, such as pharmacists, are more dependent on Medicaid reimbursement than their urban counterparts.

To view full report, visit: http://www.schsr.unc.edu/research_programs/rural_program/WP82.pdf.

Capitalizing on Rural America
Federal Home Loan Bank of Des Moines
2005

Policy and funding priorities have not kept pace with the economic diversification underway in rural America, according to a study commissioned by the Federal Home Loan Bank of Des Moines. The study, Crafting a Competitive Future, provided the platform for a recent Washington, D.C. forum on rural development issues. It is divided into three major sections: a description of the economic and social drivers and trends affecting rural America; a summary of key federal programs among the 337 identified in the report to provide financial and technical assistance; and a discussion of several strategic options for capitalizing on rural America.

The underlying conclusion of the report and guiding principle for the recommendations advanced in the strategic options section may apply to many urban areas as well "communities and policymakers should shift from the traditional focus on problems to an emphasis on rediscovering the economic value that is offered by rural regions and upon which new, productive activities can be pioneered and grown." (p. 7)

The full report is available at: http://www.fhlbdm.com/Docs/About_Us/PF/SRIReport_FINAL.pdf.

National Advisory Committee for Rural Health and Human Services Releases 2005 Report to the Secretary
Healthcare Resources and Services Administration (HRSA)
May 31, 2005

The National Advisory Committee on Rural Health and Human Services (NACRHHS) has issued its annual report to the Secretary of the U.S. Department of Health and Human Services (HHS). The 2005 Report to the Secretary: Rural Health and Human Service Issues explores and provides recommendations for HHS on four important issues related to rural health and human services. Those four issues are:

NACRHHS is a 21-member citizens' panel of nationally recognized rural health experts that provides recommendations on rural issues to the Secretary of the Department of Health and Human Services. The Committee was chartered in 1987 to advise the Secretary of Health and Human Services on ways to address health care problems in rural America. It was expanded to 21 members in 2002 and charged with focusing on both health and human service issues in rural areas.

The report and additional information about the committee can be found at http://ruralcommittee.hrsa.gov.

How Much Does Churning in Medi-Cal Cost?
The New York Academy of Medicine
April 2005

Efforts in California to simplify the enrollment process and increase outreach for children in Medi-Cal have been successful, and by 2003, the Medi-Cal program enrolled nearly 3.4 million children. Policymakers are beginning to move their focus beyond initial enrollment to ask questions about ways to keep eligible children stably insured and ways to increase cost efficiency of the system. Stability in Medi-Cal and in a health plan is important, and reducing churning is key to achieving stability for eligible children.

This report by the New York Academy of Medicine, and commissioned by The Endowment, investigates the cost of "churning" (i.e., enrollments, exits and re-entries by the same group of children) in California's Medi-Cal and Medi-cal managed care programs in order to provide state-by-state comparisons between California and four other states.

To download full report, visit http://www.calendow.org/reference/publications/pdf/access/churning.pdf.

Recent Agricultural Policy Reforms in North America
USDA
April 19, 2005

The United States, Mexico, and Canada have each made significant changes to their agricultural policies over the past several years. In the area of income supports, each country has instituted a countercyclical program that provides additional assistance to producers during downturns in commodity prices, and each continues to decouple key support programs from production decisions. In other areas, the reforms of the three countries have different points of emphasis. The United States has expanded spending on conservation activities, especially on lands in production; it has made important changes to peanut and tobacco programs; and it has implemented a new program that assists producers who are adversely affected by competition with imports. Mexico’s new efforts to strengthen the competitiveness of its agricultural sector include energy discounts for producers, and a revamped approach to agricultural finance. And Canada’s comprehensive evaluation of its farm programs is leading to new efforts concerning the environment, food safety and food quality, science, and the renewal of the agricultural sector.

To view full report, visit http://www.ers.usda.gov/publications/WRS0503/wrs0503.pdf.

Why Rural Matters: The Rural Impact of the Administration’s FY06 Budget Proposal
National Rural Network
March 15, 2005

On February 7, 2005, President Bush released his FY06 budget proposal. An administration's budget reflects its priorities, its values, and its vision for our nation. This budget is no exception. Because of the significant cuts proposed in this budget, it has received more than the usual attention. Many sectors, interest groups, and constituencies have already expressed their concerns with this budget’s implications. The National Rural Network, a coalition of over 50 organizations working together to address the concerns of rural America, released this analysis of the specific rural impacts of the Administration’s FY06 budget.

The Consolidated Federal Funds Report for 2001 (the most recent reported data) shows that the federal government returned $6,131 on a per capita basis to urban areas, while returning only $6,020 to rural areas. This results in over a $6.5 billion annual federal disadvantage to rural areas. Rural people and places have long suffered a differential federal funding disadvantage. Unfortunately, this budget proposal does not improve this situation. Instead, the priorities, values and vision reflected in this budget present an even deeper challenge for rural America.

To view the full report, visit http://www.rupri.org/getFile.asp?fileID=18326.

Snapshot: Healthcare Costs 101 2005
California HealthCare Foundation
March 2005

This snapshot provides a visual representation of costs and financing trends over the past decade, as well as predictions of future costs. Taken from several public and private data sources, the presentation is meant for anyone interested in an overview of health care financing issues in California and the nation.

For link to full report, visit http://www.chcf.org/topics/healthinsurance/index.cfm?itemID=109369.

Press Release: Congressional report shows lack of federal investment in Central Valley
Great Valley Center
February 8, 2005

Six Valley congressmen released a preliminary federal report on February 8, 2005, that shows an eight-county area of the San Joaquin Valley persistently gets the short end of the federal funding stick. A press release submitted by the Great Valley Center highlights major findings from the report.

To view full press release, visit http://www.greatvalley.org/news/docs/pr_crsreport.pdf.

Policy Implications of Racial and Ethnic Differences in Managed Care vs. Fee-for-Service Utilization Disparities in California
Robert J. Nordyke, PhD, MS and Ellen Wu, MPH for California Pan-Ethnic Health Network (CPEHN)
October 2004

This report, based on data from the 2001 California Health Interview Survey, examines the differences in utilization of services, cancer screenings, and chronic disease
management among California’s racial and ethnic groups in managed care compared with fee-for-service. The study was funded by the California Program on Access to Care. A summary of the findings include:

• The differences seen between managed care and fee-for-service are generally greater in Medi-Cal than in employment-based/private insurance.
  
• While those in Medi-Cal/Healthy Families managed care are more likely to have a usual source of care, they are also more likely to report an ER visit.
• Generally, cancer screening rates are higher in employment-based/private insurance than Medi-Cal/Healthy Families and are higher in managed care than in fee-for-service.
  
  To view the full report, go to www.cpehn.org. For more information about CHIS visit www.chis.ucla.edu.

Rural Develoment Research Report
Economic Research Service, U.S. Department of Agriculture
July 2004

This publication provides the most recent information on poverty trends and demographic characteristics of the rural poor. The rate of poverty is not only an important social indicator of the well-being of the least well off, but it is also widely used as an input in shaping Federal policies and targeting program benefits. While metro and nonmetro areas have shared similar patterns of reductions and increases in poverty rates over time, there continues to exist a wide and persistent gap between nonmetro and metro poverty rates. The report also documents large metro-nonmetro gaps when poverty is analyzed by race, ethnicity, age, and family structure.

To view the full report, go to http://www.ers.usda.gov/publications/rdrr100/.

County Residency and Access to Care for Low- and Moderate- Income Californians
UCLA Center for Health Policy Research
March 2004

This study found that the location of residence is prominently connected to the standard of health care available to Californians. Four key areas were investigated to rate healthcare quality, and they were measured by the percentage of people in the county who: 1) have a regular source of care, 2) use community or government clinics as their regular source of care, 3) are uninsured for all or part of the year, and 4) delayed any type of care because of cost or insurance issues. Additionally, the study found that health insurance plays a significant role in the level of access to healthcare in any given county. This and other information the study discusses have important implications for the Medi-Cal and Healthy Families programs. Moderate to low income children and adults in different counties do not have a set standard of healthcare throughout the state. The inconsistent care and small number of full-time insured individuals puts a large burden on community, public, and hospital-based clinics.

For more information, go to http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=89.

What would Association Health Plans mean for California?
California Health Care Foundation
January 2004

Health insurance is an important issue in rural California, specifically the large uninsured population. Since this topic is also of national concern, many different organizations are looking for ways to mitigate the problem. The California Health Care Foundation sponsored a study evaluating the new solutions to the health insurance problem that focuses on small businesses. The investigators evaluate past and current legislation, as well as the economic impact of implementing these new ideas to determine what improvements can be made to the current system.

This topic is relevant to rural California since many people are either small business owners or employees. In addition, most people get their health insurance coverage though their jobs.

For more information, and to learn the recommendations made in the study, visit:
http://www.chcf.org/documents/insurance/AHPFullReport.pdf.

The Crucial Role of Counties in the Health of Californians: An Overview
Deborah Reidy Kelch, M.P.P.A.
July 2004

This report offers a broad overview of the range of health services that have over time become the responsibility of California counties, either by statute, by practice, or by default. It outlines some of the basic requirements imposed on counties in the areas of health services for the uninsured, public health, mental health, and substance abuse treatment; the funding streams for these services and programs; and the basic structure of how counties provide the services. In addition, the report highlights the issues facing policymakers at the state and local levels that will affect the future of county health programs and services.

The state's unprecedented fiscal crisis is having and will continue to have dramatic impacts on county finances and programs. In this context, the report highlights some of the issues facing policymakers at the state and local levels that will affecting the future of county health programs and services

To access the full report, go to http://www.chcf.org/documents/policy/RoleCountiesInHealthOfCalifornians.pdf.

Does Economic Vulnerability Depend on Place of Residence? Asset Poverty Along the Rural-Urban Continuum
Rural Poverty Research Institute
March 2004

For many of the health care challenges that rural California, poverty is a factor that inhibits positive change. RUPRI sponsored a study that evaluates the correlation between location of residence and asset poverty. Asset poverty is defined as the situation when a household's income is suspended, and it doesn't have enough financial resources to maintain itself at the poverty level for at least three months. Usually, ethnic minorities have higher rates of asset poverty than the general population.

This study found that the area of residence is a better determinant for asset poverty than the members of the household (i.e. number of working men and women, number of children, etc.). Rural populations are more likely to be asset poor than urban people.

For more information, visit: http://www.rupri.org/rprc/RPRCwp04-01.pdf.

Options for Structuring Disproportionate Share (DSH)
Payments to Account for Uncompensated Care: Impact on Rural Hospitals
Walsh Center for Rural Health Analysis
Expected completion date: August 2004

This study will identify options for development of an equitable Disproportionate Share (DSH) payment adjustment that accounts for hospital uncompensated care costs, and determine the financial impact of each of these proposals on rural hospitals. A hospital's eligibility to receive DSH payments is based on a set of complex formulas that historically have been biased against rural hospitals. Compared to their urban counterparts, rural hospitals had to achieve a higher threshold of low-income patients to qualify for DSH payments, and those that did qualify for this adjustment received a lower fixed percentage add-on to the base DRG payment amount.

The Medicare, Medicaid, and SCHIP Benefit Improvement and Protection Act of 2000 (BIPA) made substantial advances toward achieving equity in the DSH formula. However, small and rural hospitals continue to be disadvantaged by the DSH because the distribution formula caps the payment to rural hospitals. Research suggests that beyond equalizing the rural and urban payment amount, more fundamental changes in the DSH formula are necessary to ensure that the original purpose of the adjustment - preserving access to care for the poor - is achieved.

Walsh Center staff will review the health services literature to identify alternative models or recommendations for revising the DSH payment adjustment and prepare a matrix that compares proposals in terms of the incentives that they promote. Staff will present results of simulations based on data from four states - Washington, West Virginia, Texas, and Iowa - to determine the financial impact of incorporating measures of uncompensated care into the DSH payment system.

Results will be presented in the aggregate as well as by selected hospital characteristics that include size, state, teaching status, and ownership. A report and policy brief will be prepared for distribution to policymakers and persons on the Center mailing list.

Principal Investigator: Janet P. Sutton, Ph.D., 301-951-5070 or sutton-janet@norc.net.

Rural Hospital Closures, 1990-2000: Community Profiles and Economic Indicators Before and After the Event
North Carolina Rural Health Research and Policy Analysis Center
Expected completion date: February 2004

This study investigated the economic impact of hospital closures in non-metropolitan counties, taking into account the economic characteristics and employment trends that may have preceded the event. Between 1990 and 2000 there were 460 community hospital closures in the U.S. that did not result from merger or acquisition. Over one third of these were in rural counties.
Some hospital closures occur in economically "at-risk" communities, but others may fail even though they are located in economically healthy areas. In both instances, the loss of the facility is likely to have an impact on the economic health of the surrounding communities.

The study included the counties of location for 129 non-metropolitan facilities identified as having stopped operations between 1990 and 1997. Using data from the Bureau of the Census, the Bureau of Economic Analysis, the Bureau of Labor Statistics, AHA surveys, Medicare Public Use Files and the Area Resource Files, the populations and the commercial base of these communities were studied for a period of up to five years before and three years following each closure.

Principal Investigator: Rebecca Slifkin, Ph.D., 919-966-5541 or becky_slifkin@unc.edu.

An Analysis of Medicare's Incentive Payment Program for Physicians in Health Professional Shortage Areas
Leighton Chan, MD, MPH, L. Gary Hart, PhD, Thomas C. Ricketts III, PhD, and Shelli K. Beaver
Spring 2004

Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians. The purpose of this report is to examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. The researchers determined the program's utilization and which types of physicians received payments.

Key findings showed: Over $4 million in bonus payments (median payment ¼ $173) were made to providers in HPSAs. Specialists and urban providers received 58% and 14% of the bonus reimbursements, respectively. Two million dollars in payments were not distributed because the providers did not claim them. Over $2.8 million in bonus claims were distributed to providers who likely did not work in approved HPSA sites.

To access full analysis, go to http://www.nrharural.org/JRH/JRH20-2/rurh-20-02-109.pdf.

Rural Healthy People 2010 Expansion: Access to Long-Term Care and Rehabilitation Services, Educational and Community-Based Programs, and Public Health Infrastructure
Southwest Rural Health Research Center
Expected completion date: August 2004

The Rural Healthy People 2010 project reviews research literature and models for practice on rural health priority areas among the Healthy People 2010 focus areas and objectives with a focus on rural urban disparities in prevalence, morbidity/mortality, barriers, and proposed solutions. This project will expand the work of Healthy People 2010 by focusing on the rural constituency, and document any associated disparities, barriers, and solutions unique to rural America.

The companion document to date addresses the following focus areas: access to quality health services, cancer, diabetes, heart disease and stroke, immunization and infectious diseases, injury and violence prevention, maternal, infant, and child health, mental health and mental disorders, nutrition, oral health, substance abuse, and tobacco use.

For the 2003-2004 project year, the project researchers plan to expand the document by adding three additional chapters and associated models for practice in the following topic areas: Access to Long Term Care and Rehabilitation Services; Education and Community-Based Programs, and Public Health Infrastructure. These three new focus areas and associated models will be added to the Rural Healthy People 2010 website at http://www.srph.tamushsc.edu/rhp2010.

Principal Investigator: Larry Gamm, Ph.D., 979-458-2244 or gamm@srph.tamushsc.edu.

Farm Policy, Farm Households, and the Rural Economy
Economic Research Service (ERS)
May 2004

Existing U.S. farm programs have their origins in the 1930s, a period when the well being of U.S. farm households and rural communities were tightly linked. Although farms, farm households, and rural communities at the beginning of the 21st century are vastly different, commodity-based support programs continue to play a central role in U.S. agricultural policy. This raises questions about whether current policies most effectively target the needs of an evolving farm and rural economy.

Numerous questions arise about market responses to policy change, and about the appropriate role of federal programs to facilitate adjustment. What are the impacts of existing policies, how are they distributed, and how would they change if policies change? Would policy reform impose significant adjustment costs on large numbers of farm households and/or rural communities? This briefing room is designed to help fill this information gap and stimulate new thinking that contributes to the ongoing policy debate. ERS research casts a wide net-covering economic, environmental, rural household and community welfare, and institutional implications-and extends both upstream and downstream from the farmgate.

To access full briefing, go to http://www.ers.usda.gov/Briefing/Adjustments.

Health Care for the Uninsured: How Do the Uninsured Use the Rural Safety Net?
WWAMI Rural Health Research Center
Expected completion date: February 2004

"Safety net" refers to the local arrangement of providers and institutions that provide care for the uninsured and those otherwise outside the traditional system of insurance, whether private or government-based. The number of uninsured and under-insured is growing at an alarming rate while the capacity of traditional safety net providers to meet growing needs is severely constrained. In many rural areas where there are few federally-funded safety net providers, the situation is worse in terms of unmet need and/or local provider fiscal burden. The safety net was examined from the community perspective in two small rural towns in Alaska and Wyoming to describe how, where, and if the rural uninsured obtain health care and to characterize the process and difficulties involved in obtaining care. Surveys were administered to generalist physicians in Alaska and Wyoming.

Principal Investigator: Sharon Dobie, M.D., M.C.P., 206-685-0401 or dob@u.washington.edu.

Why Are Health Care Costs Increasing and Is There a Rural Differential in National Data?
RUPRI Center for Rural Health Policy Analysis
Expected completion date: August 2004

This project will determine whether growth in health insurance premiums and out-of-pocket spending differs in rural areas as compared to urban areas. Rising health care spending is an increasing concern to rural residents, employers, taxpayers, and legislators. Following a six-year period in which health care spending experienced an unprecedented lull in growth, total health care spending in the U.S. grew in 2000 and 2001. The project will be conducted in two phases. First, a concept document will be produced discussing the reasons for the rise in health care costs, and whether or not we would expect to find a rural differential. Second, MEPS data over time will be used to analyze medical care costs in urban and rural areas. Two policy papers and two policy briefs will be produced.

Principal Investigator: Timothy D. McBride, Ph.D., 314-977-4094 or mcbridet@slu.edu.

The 2004 Report to the Secretary: Rural Health and Human Service Issues
The National Advisory Committee on Rural Health and Human Services
April 2004

In the last year, the National Advisory Committee on Rural Health and Human Services has expanded its focus. Five new members who are experts in the field of rural human services have been added and the Committee is now charged with advising the Secretary of Health and Human Services on human service issues in addition to rural health issues. As a result, this year's Committee report does not focus on one primary issue as it has in years past. Instead, the 2004 Report to the Secretary opens with a general overview of some key current issues and trends affecting health and human service delivery in rural communities. This overview identifies several issues that may require further analysis by the Committee in future years. The chapters that follow focus on three key issues the Committee has chosen to examine on a more in-depth level. Those issues are:

1) Behavioral health and primary care coordination in rural communities;
2) Access to oral health care in rural communities and;
3) Access to human services for the rural elderly.

Each chapter includes a summary analysis of the key issues in each topic area and a set of recommendations for the Secretary on how to address problems identified by the Committee.

To access full report, go to ftp://ftp.hrsa.gov/ruralhealth/NAC04web.pdf.

Bridging the Health Divide--The Rural Public Health Research Agenda
University of Pittsburgh, Center for Rural Health Practice: Under the direction of Michael Meit, MA, MPH.
April 2004

Bridging the Health Divide-The Rural Public Health Research Agenda reports the results of the Rural Public Health Research Agenda Setting Meeting held September 22-23, 2003, in Pittsburgh, PA. Fifty-seven rural public health experts from throughout the U.S. participated in the identification and refinement of the most important rural public health research issues. The participants were comprised of 30 representatives from academia, 12 from practice-based agencies such as state and local health departments, 8 from national organizations, and 7 from federal agencies.

While it is clear that rural citizens experience significant health disparities, the vast majority of health-related research and practice efforts in rural communities focus on assuring access to health care services. Undoubtedly access to care is an issue critical to improving health status throughout rural America, but equal in importance are issues such as health behavior, environmental health, infectious disease surveillance, and other issues of public health interest. These areas are largely unstudied relative to their impact on rural health status, leading to the conclusion that a research agenda focused on rural public health issues was needed to encourage researchers and funders to consider rural populations as they design and implement studies. By encouraging a broader focus on all of the factors that contribute to the health status of rural populations, the goal of the Rural Public Health Research Agenda is to create opportunities for public health researchers to address issues of geographic health disparities and ultimately improve the health status of rural Americans.

To access full monograph, click here.

Rural-Urban Commuting Area (RUCA)
Development Project: Demographic Description and Frontier
Enhancement
WWAMI Rural Health Research Center
Expected completion date: January 2004

There is considerable current debate and political lobbying about how to define frontier areas. Rural-Urban Commuting Areas (RUCAs) are a new census tract-based classification scheme that utilizes the standard Bureau of Census Urbanized Area (UA) and Urban Place (UP) definitions in combination with commuting information to characterize all the nation's census tracts regarding their rural and urban status and relationships.

The codes are based on whether a Census tract is located in a UA or UP and on the destination of its largest and second largest commuting flows. The methods used to accomplish the demographic description of the RUCA codes involved standard cross-tabulation analysis of the code areas nationally, regionally, and by state.

This project augments the initial RUCA work by:

• Producing and describing the base 1998 demography of the RUCA code areas
  
• Creating quality state maps of the RUCA codes
  
• Making this information and the codes easily available on the Web at http:/www.fammed.washington.edu.

Principal Investigator: Gary Hart, Ph.D., 206-685-0401 or ghart@fammed.washington.edu.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173). A Summary of Provisions Important to Rural Health Care Delivery.
Rural Policy Research Institute, Keith J. Mueller, Ph.D.
January 2004

The purpose of this Policy Paper is to provide a wide audience of rural health policy makers, advocates, and researchers a consolidated summary of legislative provisions contained in P.L.108-173 (the Act) that have particular meaning to the delivery of services in rural areas. More narrowly focused summaries exist elsewhere, for example, a summary of provider provisions is available from the American Hospital Association (http://www.hospitalconnect.com), and a summary of prescription drug coverage is available from the Kaiser Family Foundation (http://www.kff.org). A summary of rural provisions contained in Title IV of the Act (“Rural Provisions”) is available from the National Rural Health Association (http://www.nrharural.org). This document is a review of all 12 titles of the Act that are focused on rural health care delivery (Titles 8, 11, and 12 do not include a specific rural focus, although Titles 8 and 12 have implications for rural beneficiaries and are summarized in the Appendix).

To access the full report, go to http://www.rupri.org/healthpolicy/.

Preventing Unnecessary Hospitalizations in Medi-Cal: Comparing Fee-for-Service with Managed Care
University of California San Francisco's Primary Care Research Center
February 2004

The report, Preventing Unnecessary Hospitalizations in Medi-Cal: Comparing Fee-for-Service with Managed Care, prepared by University of California San Francisco's Primary Care Research Center, shows that from 1994 to 1999 the preventable hospitalization rate was significantly lower for Medi-Cal beneficiaries enrolled in managed care than those in fee-for-service.

As the state considers ways to reform Medi-Cal and reduce costs, one key element of the governor's budget proposal is to expand Medi-Cal managed care. This report released by the California HealthCare Foundation suggests that managed care is a better system to improve access and health outcomes of many Medi-Cal beneficiaries than traditional fee-for-service.

To access the full report, go to http://www.chcf.org/documents/policy/PreventableHospitalizationsInMediCal.pdf.

The Role of Provider Organizations in Medical Managed Care
Using Computerized Registries in Chronic Disease Care
California HealthCare Foundation, Diane R. Rittenhouse, et al.
February 2004

This report presents the findings from a 2003 survey of medical groups, independent practice associations, community clinics, and hospital-based delivery systems serving Medical managed care beneficiaries. It reviews the scale and scope of these organizations; their investments in information technology; self-reported measures of profitability; and interest in expanding or decreasing the number of their Medical patients.

To access the full report, go to http://www.chcf.org/documents/policy/medical/ProviderOrganizationsInMediCalManagedCare.pdf.

Impact of Proposed Budget for 2004-05 on Medi-Cal and Other Health Programs
California HealthCare Foundation
January 14, 2004

The California HealthCare Foundation has prepared a brief analysis of the impact of the Governor's proposed FY2004-2005 budget on Medi-Cal, Healthy Families, and other health programs. The report uses simple bullet points and graphs to compare this budget with previous budgets, review major program expenditure growth over the past 10 years, and examine proposed cuts to major health programs, including the potential impact these cuts would have on children, Medi-Cal beneficiaries, and on the health care delivery safety net. Also included is a comparison of Medi-Cal with other state Medicaid programs and a review of physician participation in Medi-Cal and how this affects patient access to care.

To access full report, go to http://www.chcf.org/documents/policy/CABudgetAnalysis2004REV2.pdf.

1) Insurance Markets: What Would Association Health Plans Mean for California?
2) What Would Association Health Plans Mean for California?
3) The Effects of Introducing Federally Licensed Association Health Plans in California: A Quantitative Analysis
California HealthCare Foundation
January 2004

Two new California HealthCare Foundation studies (and an accompanying Issue Brief) examine the potential impact of federally proposed Association Health Plans (AHPs) on California's insurance market. Passed by the House of Representatives and supported by the Bush administration, the legislation creates federally licensed insurance plans - exempt from state regulation. These AHPs would draw employer groups and individuals from existing market segments - currently heavily regulated by the state - leaving less of the market under state supervision.

The greatest impact of AHPs would be on California's small group market (2 to 50 employees), which is the most heavily regulated and subject to rules including guaranteed issue, guaranteed renewal, rating restrictions, and benefit mandates. According to the reports - "What Would Association Health Plans Mean for California?" and "The Effects of Introducing Federally Licensed Association Health Plans In California: A Quantitative Analysis" - AHPs would attract small businesses with healthy employees, lowering their rates. However, costs for small groups with sicker employees would likely increase. Additionally, AHPs would not reduce the number of California's uninsured.

To access full reports, go to:

Insurance Markets: What Would Association Health Plans Mean for California? (http://www.chcf.org/documents/insurance/AHPIssueBrief.pdf)
What Would Association Health Plans Mean for California?(http://www.chcf.org/documents/insurance/AHPFullReport.pdf)
The Effects of Introducing Federally Licensed Association Health Plans in California: A Quantitative Analysis (http://www.chcf.org/documents/insurance/AHPBlumberg.pdf)

Health and Disease:

The Impact of Cancer Coalitions on the Dissemination of Colorectal Cancer Materials to Community Organizations in Rural Appalachia
Ann J. Ward, MA, Brenda Coffey Kluhsman, MSS, Eugene J. Lengerich, VMD, MS, Andrea M. Piccinin, PhD
April 2006

The incidence of colorectal cancer in portions of rural Appalachia is higher than in much of the United States. To reduce this disparity, cancer-control strategies could be adapted to and implemented in rural Appalachian communities. The objectives of this pilot study were to develop and test community-based participatory research methods to examine whether cancer coalitions in Appalachia could effectively disseminate print materials from a national media campaign intended to promote colorectal cancer awareness to their rural communities.

To view full report, visit: http://www.cdc.gov/pcd/issues/2006/apr/05_0087.htm.

Tobacco Use Among Racial and Ethnic Population Subgroups of Adolescents in the United States
Ralph S. Caraballo, PhD, MPH, Sue Lin Yee, MA, MPH, Joseph C. Gfroerer, Terry F. Pechacek, PhD, Rosemarie Henson, MSSW, MPH
April 2006

Limited data on cigarette smoking among population subgroups hinder the development and implementation of intervention strategies for those subgroups. Because of small sample sizes or inadequate study formats, cigarette smoking among youths has been studied mostly among broad racial or ethnic categories (e.g., Asian, Hispanic) instead of subgroups (e.g., Vietnamese, Cuban). The objective of this study was to evaluate cigarette smoking among U.S. youths by racial and ethnic subgroups.

To view full report, visit: http://www.cdc.gov/pcd/issues/2006/apr/05_0102.htm.

Colorectal Cancer Test Use Among Hispanic and Non-Hispanic U.S. Populations
Lori A. Pollack, MD, MPH, Donald K. Blackman, PhD, Katherine M. Wilson, PhD, MPH, Laura C. Seeff, MD, Marion R. Nadel, PhD
April 2006

Although colorectal cancer mortality rates in the general U.S. population declined slightly from 1992 to 2000, the rates for Hispanic men and women did not. Disparity in colorectal cancer screening among Hispanics may be an important factor in the changed mortality trends. This study examined rates of colorectal cancer test use among Hispanic and non-Hispanic adults in the United States.

To view full report, visit: http://www.cdc.gov/pcd/issues/2006/apr/05_0120.htm.

Breastfeeding May Reduce Mothers' Risk for Type 2 Diabetes
Brigham and Women's Hospital (BWH)
November 23, 2005

While breastfeeding has long been recommended to promote babies' health, a new study from Brigham and Women's Hospital (BWH) suggests some health benefits for mothers, too. According to researchers, one year of breastfeeding may reduce a mother's risk of developing type 2 diabetes by 15 percent. To produce milk, a breastfeeding mother uses about 500 calories a day -- about as many as it would take to run four or five miles -- and this additional energy use is associated with changes in insulin and glucose levels. The study can be found in the November 23, 2005, issue of the Journal of the American Medical Association.

Read the full article at: http://www.brighamandwomens.org/publicaffairs/Newsreleases/11.232005.Stuebe.JAMA.asp.

Federal Funding for Diabetes Programs Not Keeping Pace with Disease's Advancement
Centers for Disease Control and Prevention
October 26, 2005

With 20.8 million Americans now suffering from diabetes, 7 percent of the population has the potentially deadly disease, according to the Centers for Disease Control and Prevention. As much as a third of that number are undiagnosed, meaning that they are probably not taking steps to avoid exacerbating the illness. "This study confirms what we already know: diabetes is one of this country's most prolific and deadly diseases," said Robert A. Rizza, MD, president of the American Diabetes Association (ADA). According to the ADA, federal funding for diabetes research has not kept pace with the rapid advances the disease is making among Americans, meaning that programs to avoid, delay, and manage the disease are not fully funded.

Read the full article at: http://www.diabetes.org/uedocuments/CDCnumbers.pr.102605.pdf.

Inequality in recreational resources decreases physical activities, boosts weight gain
University of North Carolina School of Public Health
February 2006

Researchers at the University of North Carolina at Chapel Hill have shed light on one factor contributing to disproportionate obesity rates among minorities and low-income individuals: less access to recreational facilities. "We expected to find that private, fee facilities would be more common in more affluent areas, but... even the types of facilities we think of as most equitably allocated, like YMCAs, public parks and youth organizations, were significantly less common in poorer areas," said Dr. Penny Gordon-Larsen, assistant professor of nutrition at UNC. The report appears in the February issue of the journal Pediatrics.

To view full article, visit: http://www.unc.edu/news/archives/feb06/pediatricspg020106.htm.

Sustainable Chronic Disease Management in Remote Australia
John Wakerman, Elizabeth M Chalmers, John S Humphreys, Christine L Clarence, Andrew I Bell, Ann Larson, David Lyle and Dennis R Pashen
Summer 2005

The Sharing Health Care Initiative (SHCI) is part of the Australian Government’s Enhanced Primary Care Package for older Australians and people with chronic and complex health conditions. The initiative aims to improve health service management and quality of life for people with chronic diseases. Between 2002 and 2004, the Australian Government Department of Health and Ageing funded eight such demonstration projects.

This project provided the opportunity for an important and timely case study to examine sustainability issues as they apply to health service reform in a remote context. Too often, successful projects, pilots and trials are not sustained, while other programs continue without thorough evaluation. The report identifies factors promoting and inhibiting the sustainability of the project, which could be generalised to other settings.

To view full report, visit: http://www.mja.com.au/public/issues/183_10_211105/wak10600_fm.html.

New HIV Therapy Found to Slow Progression to AIDS
Bristol University
July 29, 2005

A new study out of Bristol University has found that highly active antiretroviral therapy (HAART) can significantly improve outcomes for HIV-infected individuals. HAART combines three or more antiretroviral drugs from at least two drug classes. The study, published in the Lancet, found that the therapy produced an 86% reduction in the rate of progression to AIDS or death when compared to patients getting no treatment or those getting dual therapy, which was previously considered the best treatment option.

Read the full article at: http://www.bris.ac.uk/news/2005/777.

Physician Involvement a Major Factor in Diabetic Exercise Plans
Saint Louis University
May 12, 2005

People with diabetes are more likely to exercise when their doctors help them create an activity plan and stick with it. That's according to a new study published in the May issue of Diabetes Care. "Physician advice alone was not associated with regular physical activity. However, when a physician helped to make a plan for physical activity or followed up on the plan, we saw more physical activity," says Anjali Deshpande, Ph.D., assistant professor of epidemiology at Saint Louis University School of Public Health and lead author on the study.

Read the full article at: http://www.slu.edu/readstory/homepage/5654.

“What factors influence a family physician's decision to refer a patient to a specialist?”
Rural and Remote Health
July 17, 2005

A primary care physician’s decision to refer has an enormous impact on the cost and quality of care that patients receive. Appropriate referrals can result in rapid diagnosis and treatment for a patient; whereas, inappropriate referrals may lead to unnecessary tests and procedures, increased healthcare costs, added risk for morbidity, and decreased access for patients in need of subspecialty care.

Despite the large impact on health care, few studies have been performed on the referral patterns of general and family practitioners. Of the studies reported in the literature, some are outdated or performed outside the USA, and many disagree on their conclusions. Important factors identified by a 1992 British study included availability of qualified consultants and length of physician training1. A 1997 US study reports that a physician’s sex influences their decision to refer. In order to help clarify and identify influential factors pertinent to current health care in the US, a survey was designed, including selected items from previous studies, and was mailed to 2400 family and general practitioners in the US.

Read the full report at: http://rrh.deakin.edu.au/articles/subviewnew.asp?ArticleID=413.

“The Impact of Point of Care Testing on Diabetes Services Along Victoria's Mallee Track: Results of a community-based diabetes risk assessment and management program”
Rural and Remote Health
July 15, 2005

Recently, in the Australian state of Victoria, diabetes was recognized as one of the top 10 health problems for people of all ages in the rural ‘Mallee Track’ region (centered on the country town of Ouyen, approximately 400 km north-west of Melbourne, the capital of Victoria [Fig. 1]). In an attempt to improve diabetes services in this region, the Mallee Track Health & Community Service (MTH&CS), based in Ouyen, undertook a project entitled ‘Diabetes Management Along the Mallee Track’. This project was funded by a Rural Chronic Disease Initiative (RCDI) program grant from the Australian Government’s Department Health and Ageing, Canberra, and was based in part on the MAN Model of Health Promotion, piloted and developed by Centre for Advancement of Men’s Health across rural Victoria.

The primary aims of the Diabetes Management Along the Mallee Track project were:

1. To identify people at risk for diabetes and raise the level of awareness about diabetes in the general community, through the delivery of community-based risk assessment programs across the region.
2. To provide improved services for people with established diabetes across the region, through the establishment of an integrated, multidisciplinary, ‘one-stop’ service for the management of diabetes.

This article describes the use of POCT for the risk assessment and management arms of the Mallee Track program (focussing particularly on the latter), and reports the level of satisfaction among community members with diabetes, their doctors and allied health professionals with the new POCT services provided as part of this project. An initial assessment on clinical outcome measures for patients with diabetes, one-year post-introduction of the program, is made.

Read the full article at: http://rrh.deakin.edu.au/articles/subviewnew.asp?ArticleID=371.

“Mental Illness Is Chronic Disease among Young People”
National Institute of Mental Health
June 6, 2005

In what the National Institute of Mental Health has called a "landmark study," researchers have found that 50 percent of lifetime cases of mental disorders begin as early as age 14 and typically go untreated for nearly a decade. This study -- an expanded replication of the 1990 National Comorbidity Survey -- involved 9,292 English-speaking participants ages 18 and older. Details of the study appear in the June 6 issue of the Archives of General Psychiatry.

Read the full story at: http://www.nimh.nih.gov/press/mentalhealthstats.cfm.

“Reducing Body Fat through Exercise Won't Hurt Bone Density in Older Adults”
John Hopkins Medicine
May 25, 2005

Researchers at Johns Hopkins have found that moderate-intensity exercise has multiple benefits for older adults, including maintaining or even improving bone mass. Their results, which appear in the June issue of the American Journal of Preventive Medicine, are based on a program involving 104 men and women ages 55 to 75 over a six-month period. The study was part of the larger, ongoing Senior Hypertension and Physical Exercise (SHAPE) study.

Read the full story at: http://www.hopkinsmedicine.org/Press_releases/2005/05_25a_05.html.

“Reduced-Risk Tobacco Products Offer No Benefits, Only Confusion”
Robert Wood Johnson Foundation
May 4, 2005

According to the Robert Wood Johnson Foundation, University of Minnesota researchers have published a groundbreaking report that refutes tobacco-industry claims of new "safer" smoking products. These new products, called "potentially reduced-exposure tobacco products (PREPs)," do not reduce the health risks of smoking as claimed, and have other shortcomings, as outlined in the report. Solutions for clearing up the misconceptions are also provided.

Read the full story at: http://www.rwjf.org/newsroom/activitydetail.jsp?id=10146&type=2.

Perinatal Depression a Common but Widely Misunderstood Problem
Agency for Health Research Quality (AHRQ)
May 5, 2005

Despite the fact that depression among women during pregnancy may be as common as postpartum depression, it is under diagnosed and misunderstood by health-care providers, according to an evidence review by the Agency for Healthcare Research and Quality, a federal Department of Health and Human Services agency. The review points out that 5 percent of women suffer from major depression -- depression lasting more than two weeks and substantially impairing a person's ability to carry out normal daily tasks -- from pregnancy until up to 12 months after giving birth.

Read the full story at: http://www.ahrq.gov/news/press/pr2005/perideppr.htm.

Group Education Programs Effective at Improving Health of People with Diabetes
Center for the Advancement of Health
May 18, 2005

Lifestyle change has long been touted as the best means for reducing the millions of serious health complications and deaths encountered by people with type 2 diabetes, yet accomplishing such change proves difficult for most diabetes sufferers. A research review published in the Cochrane Library examined the effectiveness of group education programs and determined that patient-centered diabetes-management training is both effective in improving the health of patients and cost-effective for health-care providers to offer.

Read the full story at: http://www.hbns.org/news/diabetes05-18-05.cfm.

Underutilized Blood Test Could Reduce Rates of HIV Infection
The University of North Carolina at Chapel Hill
May 4, 2005

If patients were tested for HIV the same way the nation's blood supply is, more people would be diagnosed earlier, potentially reducing infection rates, according to research at the University of North Carolina at Chapel Hill. Antibody testing is the most common method nationwide for diagnosing the virus among patients, but a body's immune system might not begin producing HIV antibodies until more than a month after infection. By contrast, the nucleic acid amplification tests used by blood banks detect infection at the earliest possible time after infection.

Read the full story at: http://www.unc.edu/news/archives/may05/pilcher050405.html.

Descendants of Women Who Smoked While Pregnant Are More Likely to Develop Asthma
University of Southern California
April 12, 2005

Researchers at the University of Southern California (USC) have found that children are twice as likely to develop asthma if their grandmothers smoked tobacco during pregnancy, and more than two-and-a-half times as likely if both their mothers and their grandmothers smoked. "The findings suggest that smoking could have a longer-lasting impact on families' health than we had ever realized," said the study's senior author, Frank D. Gilliland, professor of preventive medicine at USC's Keck School of Medicine. The study is based on interviews with parents and guardians of 908 children in Southern California. Findings were published in the April 2005 issue of the journal Chest.

Read the full story at: http://www.usc.edu/uscnews/stories/11194.html.

Teen Abuse of Common Medications Increases at Alarming Rate
Partnership for a Drug Free America
April 21, 2005

The Partnership for a Drug-Free America® recently reported that more and more teens are abusing prescription and over-the-counter medications, according to its 17th annual national study of teen drug abuse. The study, which is said to be the largest of its kind, involved more than 7,300 teenagers across the country. It includes detailed statistics about how many children report abusing Vicodin®, OxyContin®, Ritalin®, cough medicine, and more.

Read the full story at:
http://www.drugfree.org/Portal/DrugIssue/Research/Generation_Rx_National_Study_Reveals_New_Category/Teens_Abusing_Rx_and_OTC_Medications

Research Shows Collaborative Model Offers Improved Mental-Health Care for Minorities
University of California, San Francisco
March 28, 2005

Typical barriers to mental-health care for older Latinos and African Americans are greatly reduced under a collaborative-care model of treatment rather than the traditional primary-care-provider model, according to researchers at the University of California, San Francisco. Their study was part of Project IMPACT, a national clinical trial of late-life depression that followed 1,801 men and women ages 60 and older for 12 months at 18 primary-care clinics. Results of the trial, which is said to be the largest of its kind, appear in the April 2005 issue of Medical Care.

Read the full story at: http://pub.ucsf.edu/newsservices/releases/200503281/.

Violence and Rural Teens: Teen Violence, Drug Use, and School-Based Prevention Services in Rural America
South Carolina Rural Health Research Center
March 2005

This study had three main purposes: (1) to explore the prevalence of violence-related exposures and drug use among rural teens, (2) to investigate the effects of race and gender on the risk of exposure to violence and drug use, and (3) to compare the policies and mental health care services of rural and urban schools.

This study found no evidence to support the common assumption that rural youth are protected from exposure to violence. Rural teens are equally or more likely than suburban and urban teens to be exposed to violent activities, including weapons carrying, fighting, fear of violence, and suicide behaviors.

Rural teens are at significantly greater risk of using cigarettes, chewing tobacco, crack/cocaine, and steroids than both suburban and urban teens. Of important note is the high prevalence of “crystal-meth” use among rural teens.

To view the download executive summary, visit: http://rhr.sph.sc.edu/report.html#Report4.

A For Effort: Making the Grade in Oral Health
W.K. Kellogg Foundation
February 2005

Between 2001 and 2003, Oral Health America authored three consecutive state-by-state report cards that showed stalled national progress in advancing oral health parity. Grades of C, D, and even F were all too common. Health indicators in many states remain unacceptably low. Too few Americans receive regular oral health care. Too few dentists serve the neediest areas. Fluoridation of public water supplies is still below desirable levels in many states. While it will take years to improve individual grades from previous report cards, it is critical to recognize efforts now underway that are making a difference. These models will ultimately give the nation a straight A report card in oral health.

This report card awards nine A for Effort grades to Arkansas, California, Illinois, New Jersey, New Mexico, New York, South Carolina, and Washington. Six states also receive extra credit grades for making important strides in key areas. The grades recognize new programs, policies, and progress all reinforcing the message that oral health is essential to overall good health.

To view full report, visit http://www.calendow.org/reference/publications/pdf/disparities/CaliforniaMakingProgressinOralHealth.pdf?jmid=173071667.

Diabetes Prevalence Rates Among Adults Across California Legislative Districts
UCLA Center for Health Policy Research
February 2005

This new policy brief from the UCLA Center for Health Policy Research presents diabetes prevalence rates among adults by California Assembly and Senate districts. These data are relevant to policymakers and advocates concerned with the impact of chronic conditions on the health of Californians. Estimating the prevalence of diabetes at the local level is increasingly important as rates continue to climb and the state's population continues to age and become more ethnically diverse. Diabetes prevalence rates were estimated using a small-area methodology with data from the 2001 California Health Interview Survey (CHIS 2001), 2000-2002 Current Population Surveys (CPS) and 2000 Census.

To view full brief, visit http://www.healthpolicy.ucla.edu/pubs/files/Diabetes_Prevalence_PB_022205.pdf.

Effects of WIC Participation on Children's Food Consumption
Economic Research Service
United States Department of Agriculture
February 16, 2005

This study compared consumption patterns of WIC children with those of three different comparison groups: eligible nonparticipating children living in non-WIC households, eligible nonparticipating children living in WIC households, and children living in households whose income is too high to be eligible for WIC. The study provides strong evidence that participation in the WIC program increases consumption of at least some types of WIC-approved foods.

To view full report, visit http://www.ers.usda.gov/publications/fanrr26/fanrr26-11/fanrr26-11.pdf.

What is the connection between asthma in children and overweight and obesity?
Summary of current research studies
2000-2004

As childhood obesity is receiving more attention, people are asking questions regarding its connections with asthma. This article summarizes peer-reviewed clinical, laboratory and human epidemiology studies conducted and published during the last decade - the different hypotheses under consideration, and what the data have helped us understand so far.

To view full article go to: http://www.calasthma.org/front_page/show_current/.

Asthma among California's Children, Adults and the Elderly: A Geographic Look by Legislative Districts
UCLA Center for Health Policy Research
September 2004

This policy brief highlights the geographic variations in asthma rates among all Californians for state legislative and Congressional districts. The information is particularly relevant at this time as new asthma cases continue to arise in the population. The first of-its-kind sub-county data are useful for policy makers, advocates, and medical providers who are working to address the growing problem of asthma throughout California and within local communities. Asthma symptom rates were estimated by applying a small-area methodology to multiple data sources, including the 2001 California Health Interview Survey (CHIS 2001), 2000-2002 Current Population Surveys, and the 2000 Census.

To view the full report, go to http://www.healthpolicy.ucla.edu/pubs/files/AsthmaLegDistricts_PB_092204.pdf.

Mental Health and Substance Abuse Services Among Rural Minorities
Larry D. Gamm, PhD
Summer 2004

This paper provides a brief overview of current conditions and prospects for increased access to mental health and substance abuse services among rural minorities. First, it addresses challenges in ensuring rural minorities access to needed services. Second, it considers steps to increase rural minority participation in the mental health and substance abuse workforce. The dual emphasis is on (1) reaching now the isolated, rural, and frontier minority populations in need of these services and (2) building a rural health workforce that is reflective of rural minority cultures and offers continually higher quality and sustainable services to rural and minority populations.

To view the full report, go to http://nrharural.org/JRH/JRH20-3/rurh-20-03-206.pdf

Health of California's Adults, Adolescents, and Children: Findings from California Health Interview Survey (CHIS) 2001
Public Health Institute and the UCLA Center for Health Policy Research
May 2004

A significant new report, "Health of California's Adults, Adolescents, and Children: Findings from CHIS 2001," is now available. The report provides basic health estimates for the population and is the first time a single document has addressed this breadth of information -- more than 50 health topics -- with such high statistical reliability.

Organized for quick reference to specific topics and demographic groups, the statewide results are shown in breakouts for age groups, income levels, health insurance coverage, all racial groups including Latinos and, for the first time, urban and rural American Indian/Alaska Natives plus six of California's largest Asian ethnic groups.

In conjunction with this printed report, a parallel set of county-level and regional findings for the adult population are available online. This report and its very easy-to-use online component is an excellent resource for anyone interested in public health in California.

To access report and associated tables, go to http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=91.

Breast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America: Does Proximity to a Metropolitan Area Matter?
WWAMI Rural Health Research Center
Expected completion date: August 2004

Because local cancer screening services frequently are not available in rural locations, many persons need to travel great distances to medical facilities for screening. Lower levels of education, income and health insurance coverage among rural residents and minority group members serve as additional barriers to cancer screening. However, no studies using nationally representative data have explored whether persons residing in remote rural locations fare worse on cancer screening, and few studies have examined the issue of cancer screening among rural minority group members.

For this one-year study, nonpublic use data from the Behavioral Risk Factor Surveillance System (BRFSS) will be used to explore the prevalence and trends of screening for four types of cancer (colorectal, breast, cervical, and prostate). The study will compare screening rates among various levels of rural versus urban BRFSS respondents and among white respondents versus those from racial/ethnic minority groups. This project will result in a policy brief and a working paper. A manuscript will be submitted for publication to a peer-reviewed journal, and findings will be presented at appropriate regional and national conferences.

Principal Investigator: Mark Doescher, M.D., 206-616-9207 or mdoesche@u.washington.edu

Attention from the Top? Roles of State Offices of Rural Health Policy in Preparing for Bioterrorism and Other Health System Emergencies
Walsh Center for Rural Health Analysis
Expected Completion Date: August 2004

This project will follow-up with the state offices of rural health (SORH) to identify their current involvement with emergency preparedness in rural areas, particularly in the use of funds earmarked for bioterrorism preparedness. In 2002, the federal Office of Rural Health Policy (ORHP) released its report on emergency preparedness in rural communities as perceived by directors of state offices of rural health. Results of this study indicated that although many of the state offices of rural health were participating in planning, office respondents in a number of states were concerned about their state's lack of resources for preparedness in rural areas. State directors expressed concerns over rural hospital workforce shortages and whether hospital and public health infrastructure capacity was adequate for meeting preparedness needs.

Since release of this report, billions of dollars have been used by the states to strengthen their capacity to respond to bioterrorist threats and other emergencies resulting from terrorism. While general guidelines have been issued to assist state personnel with preparation of plans for use of these funds, whether funds are to be explicitly targeted to meet rural needs depends on decisions by personnel in the states.

Walsh Center staff will re-survey rural offices of the states and re-visit issues that were raised in the earlier ORHP survey. Roles of the offices will be identified and information on the extent of office resources devoted to bioterrorism preparedness will be collected. Activities and roles of the most- and least-involved state offices will be compared. A report and Policy Brief will be prepared for distribution to policymakers and persons on the Center mailing list.

Principal Investigator: Curt Mueller, Ph.D., 301-951-5070 or mueller-curt@norc.net.

Effects of Alcohol Use on Educational Attainment and Employment in Rural Youth
South Carolina Rural Health Research Center
Expected completion date: April 2004

As they pass from teens to early adulthood,a significant portion of American youth initiate alcohol use. The rates of
alcohol use rise dramatically, from 3 percent at age 12 to 49 percent at age 20.

Previously, it was believed that strong social connections present in rural areas reduced youthful consumption of alcohol and substance abuse, but recent studies suggest that the rural-urban gap has closed. Alcohol use in youth has been demonstrated to lower educational attainment, but little is known about whether or not youthful alcohol use affects employment opportunities and lower wages. Thisstudy proposes to examine the effects of alcohol use during the teen years on subsequent educational attainment and employment in a panel of rural residents.

If the effects of youthful alcohol use are more severe and more long lasting in rural areas, then programs targeting these locales should be researched and advocated by the Substance Abuse and Mental Health Administration. This study will use a longitudinal panel study design for the period 1979 to 1998, employing the National Longitudinal Survey of Youth-1979 data set, which is an ongoing annual panel survey of persons who were between the ages of 14 and 22 in 1979.

Workforce, Infrastructure and Technology:

Advances in Rural Medical Education in Three Countries: Canada, The United States and Australia
Tesson G., Curran V., Pong R.W., Strasser R.
November 11, 2005

A number of medical school initiatives in recent years have been designed to make medical education more oriented to medical practice in rural environments. Their aim has been to produce more medical graduates willing and able to practice medicine in rural and remote areas and eventually lead towards long-term solutions to chronic problems of recruitment and retention of doctors in regions with widely dispersed populations.

This article documents a selected number of such initiatives in three countries: Canada, the United States and Australia. One important task has been to examine how the rural mandate fits within the overall mandate, the policies and practices and the curricula of the different schools. To this end, a typology of rural schools has been developed to capture such differences with an aim to understand their impact on their respective medical education programs. A second task was to reflect on the preoccupations of the academic leaders of innovative rural schools as a means of assessing where the weaknesses and strengths of these programs lie. The main focus of the article is on undergraduate medical education, although some reference is made to post-graduate residency training.

To view full article, visit: http://rrh.deakin.edu.au/articles/subviewnew.asp?ArticleID=397.

Recruiting Undergraduates to Rural Health: What the Students Can Tell Us
Orpin P, Gabriel M.
October 4, 2005

There are still large gaps in the evidence base for the effectiveness of Australian undergraduate rural coursework and placements programs designed to increase the numbers of health graduates choosing rural practice. This article reports on an online survey conducted in 2004 of health science students at the University of Tasmania, Australia, designed as a part of a long-term study to test coursework interventions by tracking students’ attitudes to, and experience of, rural practice from course entry to eventual practice.

To view full article, visit: http://rrh.deakin.edu.au/articles/showarticlenew.asp?ArticleID=412.

“Study Finds Physician Supply Increase in States with Caps on Malpractice Lawsuit Awards with the Greatest Impact on Rural Areas”
Agency for Healthcare Research and Quality (AHRQ)
May 31, 2005

The Health and Human Services’ Agency for Healthcare Research and Quality has published results from a survey of 49 states to study the impact of state malpractice lawsuit caps. They found that between 1970 and 2000, the number of physicians per 100,000 residents more than doubled in the 13 states that enacted caps on non-economic damages during the 1980s as compared to a growth rate of 83% in the states that did not cap malpractice awards before 2000.

Read the full report at: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.250.

NRHA President, Hilda Heady testified before the House Small Business Committee on the issue of malpractice reform and its devastating effect on rural health care in February of this year. To review her testimony, please visit http://www.nrharural.org/about/pdf/liabilityTestimony.pdf.

The Rural Physician Associate Program: successful outcomes in primary care and rural practice
Rural and Remote Health
June 15, 2005

The US Rural Physician Associate Program (RPAP) has trained 1063 medical students in rural communities for the past 34 years and produced 658 primary care physicians and 521 physicians who currently practice in rural communities. Read more about this successful program in this Personal View.

Link to abstract and full article: http://rrh.deakin.edu.au/articles/showarticlenew.asp?ArticleID=453.

Do benefits accrue from longer rotations for students in Rural Clinical Schools?
Rural and Remote Health
June 10, 2005

The results of this study suggest that an opportunity to acculturate students into the rural lifestyle is lost when students’ placements are insufficiently long for them to put down roots. Does this echo your experience?

Link to abstract and full article: http://rrh.deakin.edu.au/articles/showarticlenew.asp?ArticleID=414.

The Interpreter's World Tour: An Environmental Scan of Standards of Practice for Interpreters
The National Council on Interpreting in Healthcare
March 2005

In the United States, a shortage of trained interpreters has reached a crisis point. This environmental scan analyzes standards of practice from around the world to support the development of national standards that will guide training and lead to larger numbers of skilled medical interpreters.

To download full report, visit http://www.calendow.org/reference/publications/pdf/cultural/TCE0120-2005_The%20Interpreter%27s%20World%20Tour.pdf

Providing Language Services in Small Health Care Provider Settings: Examples from the Field
Commonwealth Fund
April 8, 2005

Changing demographics, along with heightened federal and state policies, have increased the need for effective models of providing services to individuals who are limited English proficient (LEP). Unfortunately, many providers are challenged by a shortage of knowledge and resources, which can create barriers to care. To assess current innovations, the National Health Law Program conducted site visits and phone interviews at small health care provider settings. Certain services emerged as "promising practices"—creative, effective methods that are replicable by other small providers. These practices include recruiting bilingual staff for dual roles (e.g., front desk and interpreter positions); ongoing cultural and language competency training for interpreter staff; using community resources like hospitals, managed care organizations, students, and volunteers; and capitalizing on underutilized funding sources. The authors include an eight-step plan to help providers develop a strategy to meet the needs of their LEP patients and the community.

To view full report, visit http://www.cmwf.org/publications/publications_show.htm?doc_id=270667.

'Factors that influence students in choosing rural nursing practice: a pilot study'
Rural and Remote Health
April 19, 2005

Nursing shortages continue globally and are especially critical in rural and remote communities. Attracting nurses to work in less populated regions presents challenges that differ from those in urban areas. This pilot study focused on self-identified factors of nursing students who expressed an interest in rural practice post-graduation. The sample included students from the USA and Canada, who were enrolled in graduate and under graduate programs of nursing, and were attending an international rural nursing conference. Findings from the pencil and paper short answer survey found those who have life experiences and connections in small communities are more likely to choose this setting. Post-graduation employment preference was reinforced by ongoing exposure to rural theory and practice settings in their programs of study. Nursing scholars may find this study useful to further examine students’ employment preferences, and to develop targeted strategies to better prepare those having an interest in rural practice. Evidence based findings are critically needed to recruit and retain nurses to address critical nursing shortages in rural regions in North America and globally.

To view full report, visit http://rrh.deakin.edu.au/articles/showarticlenew.asp?ArticleID=387

Development of a questionnaire measuring student attitudes to working and living in rural areas
Rural and Remote Health
March 8, 2005

Student attachments in rural locations have been instigated, in part to foster positive attitudes to rural practice and encourage rural recruitment. Based on medical and allied health literature, it was hypothesised that students’ attitudes to rural practice and rural life encompasses the following three dimensions: (1) community and social issues; (2) family and personal issues; and (3) professional issues. However, there are limited studies assessing attitudinal change before and after rural placement and no valid and reliable tools which examine change across all three dimensions. This article reports on the development, reliability and validity of such a tool to fill this gap in the rural health research literature.

To view full article, visit http://rrh.deakin.edu.au/articles/showarticlenew.asp?ArticleID=327.

Community Health Workers and Promotores in California
The Center for the Health Professions
September, 2004

This publication provides an overview of an emerging and unique workforce in California. Community health workers (CHWs) and promotores are public health professionals who carry out a variety of health promotion, case management, and service delivery activities at the community level. This brief describes key challenges facing the profession.
To view full report, visit http://futurehealth.ucsf.edu/pdf_files/Final_English_101104.pdf.

Evaluation of Strategies to Recruit Oral Health Care Providers to Underserved Areas in California
Kevin Grumbach, MD, Principal Investigator, Edward O'Neil, PhD, Co-Investigator, Beth Mertz, MPA, Project Director, Gena Anderson, Research Associate
July 2004