F E B RUARY 2 02 0 Culture of Health Sentinel Community Insights Rural and Small Communities Table of Introduction1 About This Report 2 Contents Health Issues Facing Rural and Small Communities 4 H E ALTH I SSU E S I N SE N TI N E L CO M M U N I TI E S Health Narrative and Influences in Rural and Small Communities 6 P E R SP E CTI V E S O N SE L F‑SU F F I C I E N CY AN D FAI TH PERMEATE H E ALTH E X P E CTATI O N S STRO N G SE N SE O F CO M M U N I T Y TI E S TO H E ALTH CO L L AB O RATI O N H E ALTH I N F LU E N C E D BY I N TE RE ST I N ADVAN C I N G E CO N O M I C O P P O RTU N I T Y Barriers to Impacting Health in Rural and Small Communities 9 U N STAB L E F I N AN C I N G C RE ATI N G TE N SI O N S I N SU STA INING H E ALTH I N I TI ATI V E S C H AL L E N G E S I N AD D RE SSI N G H E ALTH CO M P RE H E N S IVELY D I F F I C U LT Y AD D RE SSI N G S O M E H E ALTH I SSU E S AS W ELL A S H I STO RI CAL AN D SYSTE M I C CO N TE XT S Conclusions and Insights 11 M OV I N G FO RWARD References13 Cover photos: Joshua Kohanek (man inside dairy barn); Tracie VanAuken (bus in town); Josh Kohanek (man working in food processing center); Brian Adams (wooden bridge); Tracie VanAuken (church interior); Craig Fritz (woman helping older woman); Annabel Clark (farmer with tractor); Josh Kohanek (oil storage tanks); Tracie Van Auken (woman helping a person in a wheelchair onto bus) C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 Introduction The Sentinel Communities Surveillance Project, which began was designed around four Action Areas. These include: 1) Making in 2016, monitors activities related to how a Culture of Health Health a Shared Value; 2) Fostering Cross‑Sector Collaboration is developing in each of 30 diverse communities around the to Improve Well‑Being; 3) Creating Healthier, More Equitable country. In Snapshot and Community Portrait reports for each Communities; and 4) Strengthening Integration of Health community, developed between 2017 and 2018, we described Services and Systems. Sentinel Community efforts to promote the health and well‑being of their residents. F i g ure 1 : C U LT U R E O F H E A LT H AC T I O N F R A M E WO R K This report on rural and small communities is one in a set of three reports that provide insights and themes drawn from all EQUIT Y Sentinel Communities. The collection focuses on key topics that may be of value to stakeholders working to build a Culture of Health in their own communities. The other reports focus on the ACTION AREA ACTION AREA role of anchor institutions and health equity. 1 2 MAKING FOSTERING The brief report is intended to stimulate discussion about HEALTH A CROSS-SECTOR how rural and small communities address health and well‑being. SHARED VALUE COLLABORATION TO IMPROVE Definitions vary, with some definitions based on population size OUTCOME: WELL-BEING between 50,000–500,000 people and U.S. Census specifications IMPROVED POPULATION HEALTH, using a more conservative lower bound of 100,000 people (with WELL-BEING, AND EQUITY additional variance introduced by rural/urban designation). Since ACTION AREA ACTION AREA this report also features findings from counties, regions, and 3 4 CREATING HEALTHIER, STRENGTHENING states in the Sentinel Communities, we are more expansive in MORE EQUITABLE INTERGRATION OF COMMUNITIES HEALTH SERVICES the communities featured here, with most having a population AND SYSTEMS between 20,000 and 60,000 people (see Table 1 below for detailed information on population sizes). The focus on rural and small communities is merited. Many small communities—particularly those with a population of EQUIT Y less than 50,000 people or those more isolated from larger metropolitan areas—are contending with different population demographics, including shrinking and aging populations. Other common challenges to these communities are shifts in often limited revenue sources to support city services. Table 1 shows population changes in the Sentinel Communities featured in this report between 2010 and 2018, reflecting these trends. This context provides a critical opportunity to examine how social, demographic, and economic factors contribute to and/or impede the development of a Culture of Health. RWJF’s vision of a society where everyone has a fair and just opportunity for health and well‑being is represented in the Culture of Health Action Framework (Figure 1), which depicts a holistic, integrated perspective on what it takes to achieve population‑level health, well‑being, and equity. The Culture of Health Action Framework © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 1 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 About This Report Rural and small communities may have unique aspects that change (2010 to 2018) for each of the Sentinel Communities differentiate how they conceptualize, develop, identify, and featured in this report. Monona County is unique in that it is home implement approaches that relate to each Action Area in the to less than 10,000 people. Most of the remaining communities Framework. Their smaller population size and history may have populations closer to 20,000 to 60,000, with San Juan influence how health values are shaped, as well as the number County, N.M., and Midland, Texas, having larger populations and types of organizations that are available to collaborate (~120,000 to 150,000.) Oklahoma is a state with a larger total for health and well‑being. The level of financial resources and population (roughly 4 million), but we include the state given that within‑community mobility may influence the quality and quantity many communities in the state are of small size. of resources in the physical, social, and economic environment to support health. The distribution of resources may also shape how TA B L E 1 : P O P U L AT I O N S I Z E A N D C H A N G E O F R U R A L A N D S M A L L health systems are designed and services are delivered. SENTINEL COMMUNITIES Given these unique characteristics, this report aims to answer SENTINEL COMMUNITY P O P U L AT I O N PERCENT the following questions: SIZE, CHANGE, J U LY 2 0 1 8 APRIL 2010– 1. What are the critical health and well‑being issues in the J U LY 2 0 1 8 rural and small communities, and what is common across Adams County, Mississippi 31,192 -3.4% the Sentinel Community examples? Danvers, Massachusetts 27,727 4.6% Granville County, 60,115 4.5% 2. How is the narrative about health shaped and North Carolina communicated in rural and small communities? Midland, Texas 142,344 28.0% 3. What factors facilitate or impede the ability of rural and Monona County, Iowa 8,679 -6.1% small communities to positively impact the health and North Central Nebraska 44,934 -4.09% well‑being of the community? (nine‑county region) Oklahoma 3,943,079 5.1% 4. Are there particular characteristics and/or approaches in Oxford County, Maine 57,618 -0.4% how rural and small communities build a Culture of Health? Rexburg, Idaho 28,687 12.6% Sanilac County, Michigan 41,182 -4.5% For the purposes of this Sentinel Community Insights Report: Rural and Small Communities, we have selected a sample of San Juan County, New Mexico 125,043 -3.8% Sentinel Communities that intentionally represent diversity in Source: U.S. Census Bureau, Population Estimates Program (PEP), 2018. context, history, community strategy, and types of efforts pursued. https://www.census.gov/programs-surveys/popest/data/tables.html.3 The information used in this report was originally obtained SENTINEL COMMUNITIES INTERVIEWED FOR THIS REPORT through several data collection methods, including key informant Adams County, Miss. Oklahoma telephone interviews (data from a total of 157 interviews in the Danvers, Mass. Oxford County, Maine 11 communities); environmental scans of online and published Granville County, N.C. Rexburg, Idaho community‑specific materials; review of existing population Midland, Texas Sanilac County, Mich. surveillance and monitoring data; and collection of local data Monona County, Iowa San Juan County, N.M. or resources provided by community contacts or interview North Central Nebraska respondents. Interviews were conducted with individuals representing organizations working in a variety of sectors (for As noted earlier, the population sizes of these communities example, health, business, education, human services, youth vary. Table 1 shows the population size (2018) and percent development, and environment) in the community. Sector © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 2 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 mapping was used to systematically identify respondents in a range of sectors that would have insights about community health and well‑being to ensure organizational diversity across the community. We also asked original interviewees to recommend individuals to speak with in an effort to supplement important organizations or perspectives not included in the original sample. For more information about data collection, see the Community Portraits. This report is organized by the four questions noted earlier. It includes a brief summary of what is known from the literature about rural and small communities related to health issues, health infrastructure, and other factors connected to health equity, where relevant. The primary focus of the report is the insights gleaned from the Sentinel Communities. This report is not intended to provide an exhaustive research study on rural and small communities; rather, its intention is to provide information on how some communities of this size are influencing and promoting health and well‑being. Researchers, policymakers, and community leaders and practitioners may use the lessons learned in this report to continue improving health in communities of this size. Readers may try to adapt some of the examples (more information is available in the Community Portraits for each of the Sentinel Communities) and/or incorporate the facilitators presented to help avoid or address common pitfalls. © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 3 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 Health Issues Facing Rural and Small Communities There are several health and related sociodemographic issues limited health care provider supply; high rates of not having health facing rural and small communities in the United States worth insurance; and disproportionate numbers of those who are elderly summarizing briefly here. Challenges in small communities include: and/or living in poverty.7 These factors can make effectively attending to both acute and chronic health issues difficult. ● population challenges, blending rapid growth along borders On an encouraging note, according to the Environmental near larger metropolitan areas with declining city center Protection Agency, small communities are looking for ways to populations in those metropolitan areas; provide better quality of life, while also addressing economic ● declining rural populations; challenges.8 In the process, these communities confront protecting ● associated loss of farms (a large economic driver in many of rural landscapes while preserving open space; supporting walkable these communities). communities; and building public transit—all features of a healthy community. Therefore, many efforts are underway to advance These demographic tensions can create imbalances in smart growth strategies in these communities in ways that embed economic opportunity and the revenue base and have uneven health as central to planning and design. impacts on housing markets and transportation access. A Pew report4 described that rural residents are more likely to cite HE ALT H I SSUE S I N SE NT I NE L CO M M UNI T I E S problems with the availability of jobs (42% of rural residents say In the sample of Sentinel Communities profiled in this report, the this is a major problem vs. 34% of urban and 22% of suburban health issues follow the general trends noted earlier. Specifically, residents). Rural residents are also significantly more likely these communities reported limited or inadequate formal health to cite problems with access to public transportation.4 Small infrastructure; chronic stress; social isolation and related mental communities contend with enhancing economic development to health conditions; and risks posed by upstream drivers of health compete with larger urban centers, while still maintaining core (e.g., access to jobs, housing). cultural norms and values that are important to residents. In this social and demographic context, rural and small ● In the area of health infrastructure, the smaller Sentinel communities often face critical issues in health and well‑being, Communities reported limits in creating comprehensive including high prevalence of chronic disease; poor self‑reported health systems. According to the National Longitudinal health; limited access to health care services; and some Survey of Public Health Systems, in 2018, 51 percent of community design choices that detract from health. Small the U.S. population was served by a comprehensive public communities often have fewer resources to prevent and treat health system, but for nonmetropolitan areas specifically, chronic conditions and tend to have higher prevalence of the number is closer to 45 percent.9 For instance, in Adams multiple comorbidities (e.g., diabetes and asthma). Declines in County, Miss., stakeholders reported collaboration difficulties self‑reported health have been observed among white residents between health care and public health. This was principally living in small cities versus larger, urban centers. For instance, due to not having a traditional public health department a DataHaven study showed that white residents living in small, (Adams County Health Department is a county branch of and mostly working class communities in one state, reported the state department of health). This situation has frayed poorer health than their counterparts living in the larger cities the community’s ability to coordinate effectively across the in the state.5 Some of this trend may be related to the growing hospital system, clinics, and community health workers. prevalence of deaths of despair (e.g., suicide, substance abuse In Midland, Texas, similar concerns were raised about a related) influencing differential changes in U.S. life expectancy by “marginalized public health community,” which focuses on race/ethnicity and geography.6 traditional public health activities like vaccinations but not Access to health care continues to be a challenge where broader efforts like conducting comprehensive community locations of hospitals and community health centers may be health needs assessments. remote. It is well‑documented that rural and remote cities, ● In Oklahoma, expansion of telehealth services is a confronting population decline or stagnation, are challenged by critical focus given issues of remote access to health © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 4 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 care services. This has resulted in significant investment ● Sanilac County, Mich., is representative of many smaller in broadband capacity and expansion of nursing licensure communities that have faced sharp economic declines in compacts across state lines to increase access to more agriculture and manufacturing, which has in turn led to health care providers. population decreases, difficulty retaining younger working ● While Danvers, Mass., runs its own Health Division of adults, and a growing poverty rate. the municipal Department of Land Use and Community ● In North Central Nebraska, many stakeholders noted that Services, state policy does not provide dedicated state the primary challenges to improving quality of life in the funding to support local health operations. As such, smaller region have been retaining and attracting young people, communities like Danvers face resource challenges to businesses, and support services to towns and counties that maintain health initiatives. are far removed from urban centers and many amenities. ● Finally, access to health care specialists was raised in some One respondent noted, “In rural Nebraska, towns are dying. communities. For example, while Granville County, N.C., There’s no jobs, schools are consolidating. In some counties has a robust health care system relative to other similarly where there used to be three or four schools, they’re down to sized communities (due partially to its proximity to larger one. They’ve all consolidated.” metropolitan areas in the Triangle region of North Carolina), it still has challenges in maintaining specialists in areas such ● In Adams County, a challenged school system has resulted as neurology. in increasing rates of racially segregated public schools and deepened economic and racial divides in educational Another issue that emerged in some of the communities achievement. are challenges related to isolation and stress. For instance, stakeholders from Monona County, Iowa, cited isolation as one Taken together, these deficits in social determinants of their priority public health issues. The issue of isolation of health have weighed on some of the smaller Sentinel was linked to mental health problems; caring for seniors; and Communities and may be contributing to the high burden of support for children, young families, and low‑income residents chronic disease, other poor health outcomes, and persistent racial who live outside towns without reliable transportation. Related and economic disparities. to family stress, one respondent noted that in the prevailing norms of small, close‑knit communities, what are typically considered “family issues” are ignored until problems related to neglect and abuse have become chronic. “ I N R U R A L N E B R A S K A , TO W N S A R E DY I N G . T H E R E ’ S N O J O B S , S C H O O L S A R E C O N S O L I DAT I N G . I N S O M E C O U N T I E S W H E R E T H E R E U S E D TO B E T H R E E O R F O U R S C H O O L S , T H E Y ’ R E D O W N TO O N E . T H E Y ’ V E A L L C O N S O L I DAT E D. ” Given that upstream drivers or social determinants of health account for at least 80 percent of health outcomes, fostering community conditions that support health is critical. However, there are signs that communities are struggling, particularly in small Sentinel Communities, specifically related to environmental contamination, economic opportunity, and educational access. ● For example, in San Juan County, N.M., there are challenges with environmental pollution that are the result of oil and gas extraction and prior uranium mining, a factor that disproportionately affects the American Indian population. © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 5 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 Health Narrative and Influences in Rural and Small Communities While there are health challenges facing rural and small ● The Church of Jesus Christ of Latter‑Day Saints (LDS) in communities, these communities offer important insights into Rexburg has an approach to wellness that creates a link how health is described and prioritized in community planning between faith, health, and personal responsibility to family and and policy. Narrative and messaging about health is key to community. As such, the credo that most Rexburg residents awareness about health issues, as well as education about health abide by from early childhood provides a basis for a proactive promotion and disease prevention. The ways in which health is approach to healthy living. One stakeholder noted, “It’s all discussed; the factors that influence what is communicated; and intertwined because we feel like in order for somebody to feel who is communicating about health are all key elements in building the power of God in their lives, to have a spiritual connection, community interest and commitment to advancing health. they’ve got to be fed, and they’ve got to be healthy...to see life In the rural and small Sentinel Communities, there are as being this great endeavor of trying to maintain people’s several themes regarding how health is described, how it is direction towards God, but also understanding that their lives contextualized, and the role of institutions in supporting health. will be happier if they’re healthy.” In many of these cases, small population size was considered an ● In Oklahoma, faith communities are at the center of the asset, and it motivated the development and reliance on strong rural communities as a central point of connection for many community ties. We describe each of these themes related to residents. One stakeholder noted, “They’re the mental health promoting health in the following sections. services, they’re the faith services, they’re the wellness services. Pretty much, a rural pastor is dealing with a vast “ T H E R E A R E A L OT O F L I T T L E C H U R C H E S , A N D J U S T A H E AV Y array because there are less resources.” S E N S E O F FA I T H O U T I N T H E C O M M U N I T Y, TO O. P E O P L E A R E W I L L I N G ● Granville County benefits from long‑standing bonds and TO H E L P E AC H OT H E R , A L OT O F FA R M E R S L E N D E AC H OT H E R a helping environment fostered by the church and small, E Q U I P M E N T, A N D S H A R E W O R K E R S , A N D J O I N T LY H I R E T H E M . ” tightly knit communities. One stakeholder shared, “There are a lot of little churches, and just a heavy sense of faith out in PER S PECT I V E S ON S E L F‑S U F F I C I E N CY A N D FA I T H the community, too. People are willing to help each other, a PER MEAT E H E A LT H E X P E CTAT I O N S lot of farmers lend each other equipment, and share workers, One of the themes that emerged in analyses of small Sentinel and jointly hire them.” Communities centers on expectations of self‑reliance and personal responsibility. Communities of this size often communicated ST RO NG SE NSE O F CO M M UNI T Y TI E S TO HE A LTH about health in the context of “take care of yourself” notions CO L L AB O RAT I O N and not being a burden on social services or systems. One of the clearest themes from smaller Sentinel Communities was the emphasis on sense of community and how the value ● In North Central Nebraska, stakeholders noted that there placed on community was leveraged for health collaborations. is an independent, self‑reliant mindset, but that can mean Small communities were bonded by this sense of community residents are proud and reluctant to ask for assistance, through a variety of mechanisms—including adverse community including in the area of health. experiences; an ingrained sense of volunteerism; necessity ● Stakeholders in Sanilac County noted that self‑reliance can borne from smaller networks of organizations; and limited assets be a barrier to use of preventive health care. One respondent available in these communities. noted that the mentality is often, “If it’s not broken, don’t fix it.” Monona County, which experienced a devastating tornado in 2011, leveraged that adverse experience to launch community In addition to notions of self‑reliance, expression around well‑being initiatives focused on improving the built environment. religion influences health discussions, particularly in small These recovery efforts highlighted the strength of volunteer communities with strong emphasis on faith‑based institutions. efforts; the faith community; and the benefits of small population, © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 6 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 which fostered a willingness to help others. Those that were geographical sprawl has led to partnerships that extend involved in the recovery noted that the tornado disaster health services in parts of the county where they did not delivered the residual benefit of more community cohesion, previously exist. These realities have facilitated greater which in turn influenced the success of efforts to improved collaboration between sectors and created new opportunities community health and well‑being. for residents to receive services for a variety of needs. However, the challenges of adverse experience are not While the effects of these collaborations are localized, they always bonding. For instance, in Oxford County, Maine—rural demonstrate an integration of services that help residents poverty, economic hardship, and an aging population—can streamline their care and bring various stakeholders into contribute to isolation and a general decline of community alignment around goals for improving mental and physical engagement. Several respondents noted that a primary goal in health in the county. their work—and a driver of better health outcomes—is helping ● In Rexburg, the strong social network created by the LDS residents overcome disconnection; feel they are valued; and build church can facilitate referrals and help spread information stronger community ties. One respondent shared, “We know about resources outside the church’s structure. One isolation and disconnect perpetuates trauma, perpetuates poor respondent noted, “If you’re working at the hospital as a health choices and perpetuates negative health outcomes.” crisis nurse or a social worker, you tend to be LDS … and so it’s all intertwined. If someone knows that their neighbor is The county is trying to re‑establish community activity affected having trouble, they’d probably be able to say, ‘I know about by economic downturn as a way to build health collaboration this crisis center’.” and improve community mental health. Commitment to ● In North Central Nebraska, the North Central District Health volunteerism and community service are common strengths in Department (NCDHD) unites the nine counties into one small Sentinel Communities. contiguous area. While the NCDHD has managed to connect with many different stakeholders in the counties it oversees, ● In Danvers, this commitment fostered a sense of shared values the department’s small size and the geographic distance and common purpose, which then translated to an interest in between communities and residents present ongoing improving community well‑being and engaging volunteers in challenges to its efforts. Thus, the NCDHD must partner health promotion events and community festivals. with North Central Community Care Partnership, a nonprofit ● Granville County is increasing volunteerism as a strategic organization, to create links to the community, use local objective of county governance. One stakeholder noted, media, and create informal partnerships with faith‑based “We’ve noticed that one of the cultural shifts has really been organizations, local law enforcement, and other community around this social equity. We see more young people wanting stakeholders to help increase awareness of community to do some volunteer work prior to starting their careers. We health concerns. also see some of our older generation, it’s time to retire, but they’re nowhere close to really wanting to give up work. They really want to volunteer.” “ W E K N O W I S O L AT I O N A N D D I S C O N N E C T P E R P E T UAT E S T R AU M A , P E R P E T UAT E S P O O R H E A LT H C H O I C E S A N D P E R P E T UAT E S N E G AT I V E H E A LT H O U TC O M E S . ” Sense of community is also nurtured through the relative size of the organizational network to promote health. For small communities, the network of organizations is often limited and/ or geographically dispersed, which can create difficulties but also force cross‑sector collaboration. ● In Oxford County, the combined challenge of eliminated or inconsistent funding, limited human resources, and © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 7 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 HEALT H INFLU E NC E D BY I N T E R E ST I N A DVA N C I NG ECONOM IC OPP ORT U N I T Y As noted earlier, many small communities are challenged by boom and bust cycles in economic opportunity. For some of the small Sentinel Communities, interest in advancing economic well‑being in the city is either directly tied to health or health becomes a by‑product of activities focused on prosperity. In Oklahoma, tribal communities are creating a more holistic approach, which ties together health and economic outcomes. Forward‑thinking tribal nations are implementing a progressive vision for health and well‑being that ties together the physical, emotional, economic, environmental, and cultural well‑being of their communities. Tribal governments have used their sovereignty to create integrated and culturally relevant health care systems. “ IF WE CAN GET PEOPLE OUT OF THEIR CARS AND ON THEIR FEET A N D B I K E S , G O I N G TO T H E G R O C E R Y S TO R E , O R T H E L I B R A R Y, O R T H E C O M M U N I T Y C O L L E G E , O R TO T H E R E C R E AT I O N S I T E S , T H E N W E W I N ON ALL KINDS OF FRONTS. ” Granville Greenways—a partnership between Granville County, municipalities, the school district, and other stakeholders—created a platform for expanding recreation areas, green spaces, and biking trails and highlighting the value of physical exercise. While improving health and overall well‑being for residents provided the initial impetus, the Greenway project has become an important example of the county’s ability to link promoting health and wellness with economic development and overall community improvement. One stakeholder shared, “If we can get people out of their cars and on their feet and bikes, going to the grocery store, or the library, or the community college, or to the recreation sites, then we win on all kinds of fronts.” © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 8 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 Barriers to Impacting Health in Rural and Small Communities The context of prevalent health issues and unique influences in augmenting efforts to strengthen health infrastructure. The on health narratives fosters interesting conditions to advance county has leveraged that status to expand opportunities for health and well‑being in rural and small communities. Sentinel health students and link with nonprofits to expand health service Community analyses surfaced some of the key facilitators reach. The McKenzie Health System expanded the definition and barriers to positively affecting health outcomes in small of health provider to include nurse practitioners and physician communities. While the influences on health, such as sense of assistants and offers advance‑practice rotations, particularly in community may be viewed as facilitators—there are barriers to partnering with medical schools at Central Michigan University health that are particularly acute in small Sentinel Communities and Michigan State University to make clinical rotations available related to unstable financing; ability to address health policy to medical students. Sanilac is part of the Rural Thumb Network, holistically; and comfort to examine sensitive health topics a nonprofit organization of health care organizations in the including structural and historical drivers of health equity. three “thumb” counties of Sanilac, Huron, and Tuscola, to work with Michigan State University’s College of Medicine to attract U NSTA BLE FI NA NC I N G C R E AT I N G T E N S I O N S I N medical students and advance practice health professionals SU STA INING H EALT H I N I T I AT I V E S who may begin careers in these communities. While efforts like One of the difficulties in maintaining health activities in these in Sanilac County are promising in strengthening and small communities is the relative robustness of financing to diversifying how the health care provider network is supported, consistently support those efforts. As noted earlier, health these initiatives are not always robustly funded and thus can be infrastructure can be compromised due to funding limits that subject to changes if programs are not resourced at the same cannot support a health department or uncertain amount of level each year. resources year to year to support health programs. Small Sentinel Communities also reported difficulties in maintaining a health CHALLENGES IN ADDRESSING HEALTH COMPREHENSIVELY workforce. Efforts to recruit providers, sustain health workforce Some of the small Sentinel Communities described challenges in development, and maintain critical health care centers can face approaching health in ways that can allow for integrated health serious economic challenges. These difficulties are connected to policy or holistic approaches. While the issue of working in silos is concerns about demographic shifts, particularly in places where not only a barrier for rural and small communities, the experience the population is aging or declining. of these communities suggests that some of the features Oklahoma offers a good example at the state and local described earlier of small but dispersed organizational networks levels of the issue of unstable health financing. In recent years, made it especially challenging to create health in all policies or the state health department has experienced major budget comprehensive health plans. shortfalls and overall financial cuts, reducing confidence in state As noted earlier, Monona County has leveraged community health leadership. Some of this is due to management of health disaster to build will toward community well‑being. But, formal resources, and some has been impacted by overall economic collaborations to actually promote well‑being have taken time vitality of communities in the state. The state’s current fiscal to take shape because there is no comprehensive governing crisis has forced communities to build their own governmental structure and resource models to support the effort. The Monona infrastructure to compensate for the absence of state resources County Wellness Committee has been creating the structure to and services. That infrastructure is reliant on a small, or at least promote well‑being. It has the potential to support the health uncertain, tax base and limited resources from philanthropy. As department to build a more ambitious wellness agenda and serve such, communities in the state can find it difficult to start and to facilitate collaboration with regional stakeholders, district sustain efforts to address some of the state’s leading health issues, schools, and residents. But, maintaining committees like these such as cancer or obesity. are challenged by the time required for collaboration and in For some communities like Sanilac County, being some small communities, the sheer geographic dispersion to designated as a health provider shortage area has been helpful bring organizations together. © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 9 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 In addition to having collaboratives with a broader well‑being these longstanding issues can be difficult if open dialogue is not or health and wellness lens, small Sentinel Communities reported supported and the culture is to avoid difficult conversations. For difficulties in taking a full policy approach to health. In Oxford example, in San Juan County, there are growing efforts to consider County, the government is working to break down barriers and racism as it affects the Hispanic population and members of tribal silos in how health services are delivered and cross‑sectoral nations. But fear related to racial profiling continues to inhibit collaborations are supported. There is growing interest in community engagement, and thus it is challenging to engage promoting holistic well‑being‑driven initiatives around topics diverse populations in health dialogues when the population like resilience and trauma. But assuming the whole health is afraid to participate in community institutions, use health approach is not easy given the unstable financing noted earlier care, or generally stand out in a relatively small geography. The and coordination across disparate sectors. Further, some of political context and a lack of history in speaking frankly about the innovations in health in all policies are not always easily racial issues can create particular complexities in addressing transferred from larger cities, nor do these small communities health equity. In Granville County, there has not been a history always have access to these promising approaches to make the of meeting the needs of the Hispanic/Latino population, so policy changes required. One stakeholder noted, “We need some fostering those collaborations is only just starting. Racial issues serious changes in policy and how we are structured in terms more broadly are difficult for stakeholders to address directly. of how we support our educational systems—and how we silo a The trust between white and black segments of the population child by health need, education need, mental health need—rather is an ongoing issue, and there have been few long‑term health than looking at the whole health of our citizens and really looking strategies that take a racial equity lens. at policy around all of that.” “ WE NEED SOME SERIOUS CHANGES IN POLICY AND HOW WE ARE D I F F I C U LT Y A D D R E S S I N G S O M E H E A LT H I S S U E S A S S T R U C T U R E D I N T E R M S O F H O W W E S U P P O R T O U R E D U C AT I O N A L W E L L A S H I STO R I C A L A N D SYST E M I C C O N T E X T S S Y S T E M S —A N D H O W W E S I L O A C H I L D BY H E A LT H N E E D, E D U C AT I O N While the sense of community and close connections in rural and N E E D, M E N TA L H E A LT H N E E D — R AT H E R T H A N L O O K I N G AT T H E small communities can facilitate creative approaches to working W H O L E H E A LT H O F O U R C I T I Z E N S A N D R E A L LY L O O K I N G AT P O L I C Y on health and other community issues, the relative “smallness” A R O U N D A L L O F T H AT. ” and the associated culture of that characteristic can create barriers to addressing health issues openly and completely. Topics like mental health, family trauma, sexual health, and substance use can be difficult to explore in these communities, where diversity and history of candidly discussing health is not easy. Further, how small communities address historical and systemic drivers of health equity can also be impeded by a lack of experience. In the area of tackling sensitive health topics, Rexburg provides a good case example. The community’s “pioneer heritage, pull‑yourself‑up‑by‑the‑bootstraps” mentality can create a barrier to seeking outside or professional help for mental health problems. The tight-knit nature of the community and its deep connection to a faith‑based institution can create strain from raising large families and living up to the standards of the community and its leaders. One stakeholder noted, “If someone doesn’t quite fit the mold, there’s a lot of stress, a lot of anxiety associated with that.” Further, the lack of diversity in the community can place extra pressure on youth, who find it difficult to maneuver in the prescribed LDS social structure. Systemic and historical issues are important to tackle in community efforts to address health equity. But, addressing © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 10 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 Conclusions and Insights Insights from rural and small Sentinel Communities provide ● Strengthening the Integration of Health Services and important information about how these communities are Systems. Health care access remains difficult in most of leveraging their size and their culture to promote health and yet the profiled Sentinel Communities. Given that context, tackling barriers to provide health services within the limits of being able to integrate health care, public health and social organizational capacity and infrastructure. A key theme that services can also be challenged by not having a robust is quite resonant across small communities is the agility and health infrastructure, particularly a well‑resourced health creativity employed by communities of this size to pool limited department. Small communities are advancing creative resources to promote health and well‑being. Many stakeholders solutions in regional health networks, but that can be described efforts to build networks across remote geographic strained by uncertainty or instability in financing. areas and sectors to stretch resources and create multipurpose opportunities to advance health. The Sentinel Communities were M OVI NG FO RWARD clearly working within the context of the dual influences of small This Community Insights Report is a first step in summarizing size—balancing views that foster a sense of community and insights from early analyses of rural and small Sentinel spirit of collective action—with others having self‑sufficiency Communities. This analysis highlights for further exploration mindsets that tend to avoid formal health services for particular how health is shaped, prioritized and addressed in communities health concerns. of this size: Findings reveal common themes in building a Culture of Health in rural and small communities, aligned with the Action ● Better understand how small communities overcome Areas of the Framework: or integrate self‑reliance perspectives into health promotion. One of the consistent themes from the small ● Making Health a Shared Value. Small communities build Sentinel Communities is that there is a strong sense of on a shared sense of community to promote health and independence and a disinterest in relying on social systems. leverage a strong focus on civic engagement such as It is important to better understand how: this independence volunteerism to address health issues. Health’s role in the ultimately influences timely use of preventive services; this balance between individual self‑reliance and community shapes how community leaders discuss healthy behaviors; action can create tensions in how health is prioritized in and community institutions are viewed in terms of their community plans and policies. responsibilities for promoting health and well‑being. ● Fostering Cross‑Sector Collaboration to Improve ● Examine collaboration, governance, and other structures Well‑Being. Small communities are bringing in sectors that can promote health policies. The Sentinel Community outside of traditional health to address concerns around findings to date, suggest that there are innovations in how topics like health care access and mental health. Much of health networks and collaborations are being supported this cross‑sector collaboration is motivated by necessity and sustained, yet we do not have full information on these given limits in what health care and public health can do with models. Additional analyses are needed to understand limited purview and/or resources. effective models of health decision‑making and policy ● Building Healthier, More Equitable Communities. How development in communities that are rural and small— communities are addressing the built environment with particularly when the breadth or depth of formal institutions particular attention to upstream and social determinants (e.g., health department) is limited by community population of health is variable—because many of these issues of size and resources. Further, inquiry about how small economic opportunity, environmental quality, and healthy communities build community health plans, health data community design are challenged by demographic and infrastructure, and other supports to consistently monitor economic volatility in the communities. But, communities and intervene on health issues is needed. that are successfully tying health to economic ● Explore how rural and small communities leverage broader development are finding ways to advance progress in this networks to identify and integrate new health ideas. Action Area. Some of the communities profiled in this report described © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 11 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 broader collaborations for health through regional networks, state extension programs, and cooperative grant programs. Further, some communities in Oklahoma, among other places, are expanding internet connectivity to build the health care workforce. But it is unclear if this connectivity is increasing access to other innovations in health from outside the community. It would be useful to examine whether rural and small communities that are able to access ideas and promising practices from other places more readily are able to pursue more holistic approaches to health and address emergent health issues. ● Examine how health equity is addressed in small communities. Small communities are addressing equity issues both in the upstream drivers of health but also in fostering dialogue about historical barriers to health. More study is needed to understand what is difficult about equity discussions and equity‑based planning, and what characteristics, if any, are specific to communities of this size. Understanding these differences has implications for what lessons can be transferred from larger communities addressing equity, as well as which tools are used to effectively communicate about systemic drivers of health equity in small communities. ● Unpack any notable differences between small communities. At the outset of this report, we described the broad definition of what counts as a small community for purposes of inclusion in this report. However, there are distinctions that need to be further understood regarding the diversity among small communities. More midsize communities have some of the same health infrastructure challenges, but not at the same scale of much smaller communities. However, in this first analysis, it is difficult to delineate unique attributes across small community sizes with respect to health. Plus, the research literature tends to focus on rural components of small communities and less on the characteristics of less rural, small communities and how these factors influence health processes or outcomes. This Sentinel Community Insights Report covers key topics that may be of value to stakeholders working to build a Culture of Health in communities of similar size. This report on rural and small communities highlights what is known currently from the Sentinel Communities, but more work is needed to fully unveil how the strengths of these communities can be more effectively utilized to advance health and well‑being over time. © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 12 C U LT U R E O F H E A LT H RURAL AND SMALL COMMUNITIES SENTINEL COMMUNITY INSIGHTS F E B R UA R Y 2 0 2 0 References 1. United States Census Bureau. 2018. Population estimates program. Available from: www.census.gov/quickfacts/fact/table/US/PST045218. 2. Frostenson, S. 2017. The death rate gap between urban and rural America is getting wider: The simple fact of where you live can have a huge impact on your health. Available from www.vox.com/ science‑and-health/2017/1/13/14246260/death-gap-urban-rural- america-worse. 3. United States Census Bureau. 2019. Population and housing unit estimates tables. Available from: www.census.gov/programs-surveys/ popest/data/tables.html. 4. Parker, K., Horowitz, J.M., Brown, A., Fry, R., Cohn, D., and Igielnik, R. 2018. Demographic and economic trends in urban, suburban and rural communities. Available from www.pewsocialtrends. org/2018/05/22/demographic-and-economic-trends-in-urban- suburban-and-rural-communities/. 5. Connecticut Health Investigative Team. 2019. Whites in midsize cities report poor health compared to counterparts in urban centers. Available from www.ctdatahaven.org/blog/whites-midsize-cities- report-poor-health-compared-counterparts-urban-centers. 6. Muennig P.A., Reynolds, M., Fink, D.S., Zafari, Z., and Geronimus, A.T. 2018. America’s declining well‑being, health, and life expectancy: Not just a white problem. Available from https://ajph.aphapublications. org/doi/10.2105/AJPH.2018.304585. 7. National Rural Health Association. 2019. About rural health care. Available from www.ruralhealthweb.org/about-nrha/about-rural- health-care. 8. United States Environmental Protection Agency. 2019. Smart growth in small towns and rural communities. Available from www.epa.gov/ smartgrowth/smart-growth-small-towns-and-rural-communities. 9. Robert Wood Johnson Foundation. 2019. Improving access to health care and services. Available from www.rwjf.org/en/cultureofhealth/ taking-action/strengthening-services-and-systems/access-to-care.html. © 2020 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Rural and Small Communities 13