Rural Healthy People 2030, with Timothy Callaghan and Morgan Kassabian

Organizations and resources mentioned in this episode:

• Rural Healthy People 2030
• Southwest Rural Health Research Center (SRHRC)
• Healthy People 2030
• Office of Disease Prevention and Health Promotion (ODPHP)
• Rural Healthy People 2030: Common Challenges, Rural Nuances policy brief
• National Rural Health Association (NRHA)
• American Hospital Association (AHA)
• Centers for Disease Control and Prevention (CDC)
• National Organization of State Offices of Rural Health (NOSORH)
• Federal Office of Rural Health Policy (FORHP)

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. This is an episode about the Rural Healthy People 2030 initiative.

Today I'm talking to Dr. Timothy Callaghan and Morgan Kassabian. Timothy is an associate professor in the Boston University School of Public Health, and he's affiliated with the Southwest Rural Health Research Center. Morgan is a doctoral student who contributed to the Rural Healthy People 2030 project while working with the Southwest Rural Health Research Center.

Can you tell me about the Healthy People initiative and how Rural Healthy People grew out of it?

Timothy Callaghan: So the Healthy People Initiative is a nationwide initiative run by the U.S. Department of Health and Human Services. And the goal of the national Healthy People initiative is to help individuals, organizations, and communities across the U.S. sort of improve their health and wellbeing. It's been around for about five decades, going back to 1980. And the program works to try and outline public health priorities for the nation to strive towards. So by sort of setting goals for health improvement, and trying to achieve those over time. So that's been going on for several decades. And a companion piece to this Healthy People initiative that our research center, the Southwest Rural Health Research Center, has worked on over the past several decades, is the Rural Healthy People initiative. We're going now into the third iteration of the Rural Healthy People initiative. And the goal of Rural Healthy People is to recognize that while targeting health improvement through objective metrics is great, rural communities tend to struggle to achieve some of those objectives as compared to urban communities. And through the Rural Healthy People initiative, we try to help identify which of those Healthy People priorities are most important for rural America, so that with the limited funds and resources and manpower that rural Americans have, they can prioritize the targets that really matter to them.

Andrew Nelson: You've recently published a policy brief called Rural Healthy People 2030: Common Challenges, Rural Nuances. How did you go about recruiting participants for this study?

Timothy Callaghan: We sort of followed the same basic protocol that's been followed for past iterations of Rural Healthy People, which is sort of a multi-prong approach. The first part of our approach was to reach out to prominent health organizations across the country because our target population was what we called rural stakeholders, which was individuals who work in jobs designed to improve the lives and health of rural Americans. And we thought one of the best ways to get these individuals was to talk to health-focused organizations who have large participant lists or member lists who might include these individuals. So we actually spent quite a bit of time building partnerships with organizations like NRHA [the National Rural Health Association] and the American Hospital Association and the CDC [the Centers for Disease Control and Prevention] and the National Organization of State Offices of Rural Health, and a wide variety of other organizations to help us disseminate the survey. And they disseminated our survey across the country multiple times. And that got us a large number of participants. That was step one.

Step two was every single person who took our survey was asked if there were other people who were also rural stakeholders that we should be talking to, and we asked them who those individuals were and for the contact information, then we reached out to them as well. And then the last thing we did with the last iteration of Rural Healthy People, which was Rural Healthy People 2020, we asked individuals as they downloaded that multi-volume book if they were interested in providing their contact information. And our logic being, if you are interested enough to download and closely read a multi-volume book on Rural Healthy People, you are likely a rural health stakeholder. So we reached out to those individuals as well and asked them to participate. And by doing all three of those, we gathered a pretty large sample.

Morgan Kassabian: Yeah, I would just add to that, that the process was very intentional. And so when we talk about building those relationships with AHA and others, we also went to conferences and were manually, person-to-person, boots on the ground, trying to get the word out, facilitate those partnerships. We had a lofty goal for how many participants we wanted; again, we really did our best to get there.

Andrew Nelson: What difficulties did you have or what limitations were there in terms of survey responses in the past, and what were your engagement goals for Rural Healthy People 2030?

Morgan Kassabian: So I think one big barrier to getting responses is that the rural health stakeholder population is not well-defined. There's not been many other researchers pursuing that population; providing surveys to them. So we didn't have the option of going through a big national survey firm to get this population and reach out to them. So it was all very intentional on our part to reach out, to brainstorm, to find these folks. So we've been able to kind of build upon prior years. So for example, 2020, I believe there were about 1,200 respondents that we were able to get. So we were able to have that database of those who have engaged with Healthy People 2020 products, and then reach out to them. So we also, you know, can build on that, but facilitate the new relationships. And I believe we ended up around 1,500 respondents.

Timothy Callaghan: Yeah. So, so in terms of progress over time, if you look at the three iterations of Rural Healthy People, the first iteration sample was quite small. And there was a massive improvement between Rural Healthy People 2010 and Rural Healthy People 2020. And then we've continued to make strides and increase our sample size a bit more compared to Rural [Healthy] People 2020. So we were happy. We were a little concerned about how lofty we set our goal, but we were able to achieve that with this latest iteration.

Andrew Nelson: Yeah. What were some new objectives you identified for Rural Healthy People 2030?

Timothy Callaghan: So I think we had a couple major objectives, and then we were thrown kind of a wrench by the design of Healthy People itself, but our primary objective was to see how things have really changed over the past decade. So this has been a pretty transformational decade for public health and how we think about public health. For example, an increasing emphasis on social determinants of health. We've also seen a much greater emphasis on rural health in certain parts of the federal government, an interest in rural in general in the federal government. So we were really interested to see how things might have changed over the past decade.

Another unexpected piece, because we've been planning Rural Healthy People 2030 for the past two years, was we unexpectedly had a new objective, which was to try and figure out the extent to which the public health pandemic might shape responses. So if the pandemic's going to fundamentally change the way people see health, we were curious how it might change the most important objectives for health in rural America.

And then I think the last piece is, the way we track Rural Healthy People is we look at the most important priorities of all of the priorities laid out by the Healthy People initiative. And between Healthy People 2020 and Healthy People 2030, the federal government massively increased the number of priorities and objectives that they were tracking. So our task was also, from an objectives perspective, to see how a lot of those new priorities — for example, related to the social determinants of health — might influence changing attitudes about the top 10 and top 20 priorities for rural health.

Morgan Kassabian: I would agree with that. The design was kind of a challenge because Healthy People 2030 or Healthy People when they redid the survey massively expanded it, categorized things. They made it much more usable for the everyday user. Say, for example, I am at an elementary school and I'm interested in what I can do to contribute to the health of rural America or America in general. So I can go in and click schools and see the priorities that align with that. But the problem becomes that within social determinants of health, there's also a priority for education access and quality. So we had sometimes dueling or duplicative priorities that we had to include on the survey. So that is a limitation that we faced or a challenge.

Andrew Nelson: Yeah. what are some of the rural health priorities that you've seen are consistently in the top 10?

Timothy Callaghan: I mean I don't think a lot of the top 10 historically are going to be a big surprise. I mean, certainly chronic conditions like diabetes or obesity are always going to be pretty important. We've also seen healthcare access as historically an incredibly important one as well. And then there's others that have jumped to the fore in the past decade. But I would say historically speaking, chronic diseases and healthcare access have been really important both in rural America and America in general.

Morgan Kassabian: Another one that sticks out to my mind is vulnerable populations. So I believe older adults has been consistently up there, as well as children and child-related priorities. So also an emphasis on that. Nutrition and healthy eating, obesity as concerns for rural health stakeholders.

Timothy Callaghan: The goal of Healthy People is to look at the nation as a whole. And when you're looking at the nation as a whole, you're inherently looking at urban and rural populations. I think the trouble comes in the sense that rural Americans make up about a fifth of the U.S. population, which suggests that about four fifths of what's being considered in Healthy People in general is going to be focused on the urban population majority. So if there are unique health needs for rural populations, those might get lost in the wash in terms of focusing on the entire population as a whole.

Morgan Kassabian: This is evident too, when you look at progress towards goals in prior years. So Healthy People 2020, for example, we've seen rural America lag behind urban America in reaching those targets that have been set out. And I think Dr. Callaghan makes a great point when he says that those priorities were kind of outlined for the majority, and there wasn't necessarily attention, specific attention, paid to rural America.

Andrew Nelson: For sure. Could you expand a little bit on the changes there have been in rural health concerns over the last couple of decades and last couple of iterations of Rural Healthy People?

Timothy Callaghan: Yeah. I think there's sort of the good news and the bad news. I think the good news is that when you look at certain chronic conditions like diabetes and heart disease, those priorities have actually decreased in importance over the past several decades for Rural Healthy People. They're still important, but the relative importance has dropped. Another major one that has dropped, which is an indication of good news, is tobacco use. Tobacco use has dropped in importance across the country as the United States has gotten much better at making clear the dangers of tobacco. But at the same time, other priorities have skyrocketed up the lists of priorities because there are real problems in this country. And, and the two that really stand out are mental health and mental disorders and substance abuse. And the substance abuse one has very clear ties to the opioid epidemic, which has been a major issue in the country for the past several years.

Morgan Kassabian: I'd agree. I'd also say that economic stability came up in this year's iteration. It's a new priority added for Healthy People, and our survey is unique in that it was deployed during the pandemic. So it really well captures what was top of mind for rural health stakeholders.

Andrew Nelson: While conducting your surveys, you noticed that sometimes you'd get a disproportionate response from certain geographic areas. How did you factor this into your research?

Morgan Kassabian: Sure. So this was definitely top of mind for us. It came up in every meeting, how do we pursue balance as much as possible, but again, because we weren't able to go with one of these national survey firms and sample the nation at an equal level, and a lot of our recruitment was word of mouth and snowball sampling and left up to the organizations in terms of who would respond through those organizations. For example, one of our partnerships was with the State Offices of Rural Health. So if one particular State Office of Rural Health was a little more vocal in trying to get participants, then we would achieve a disproportionate amount of responses from that area. So the best that we could, we just kept monitoring it and pursuing our partnerships further in those states that may be lacking, reaching out directly to those states that we saw lower response levels for. And so it definitely was a limitation. We wish we could have achieved more balance, but we actively worked against it throughout the entire survey administration period.

Timothy Callaghan: Yeah, and building off of what Morgan just said, I think there's a few other things to keep in mind too. I think the most important thing to keep in mind is that since there's no such thing as a truly representative sample of rural stakeholders, we don't really know what the distribution should be across states. So in some sense, that becomes difficult. It's certainly likely to be true that a state like Texas would have a larger rural population and therefore more participants than a state like Rhode Island would. And, you know, we have to recognize that certain states are inherently more rural, so not having equal numbers of participants across states might actually be reflective of what the rural populations really look like. I also would note that while we were constantly striving to make our sample as high quality as possible, it is nonetheless true that we are certainly underrepresenting certain groups in our sample, despite our efforts.

For example, I would say that we're likely underrepresenting certain Native American groups in our sample. And in terms of race in general, our sample is lacking some of the diversity we might have expected in the rural stakeholder population. And that's raised some really interesting questions for us because we know that rural America itself is incredibly diverse, but the question that we were left with at the end of our sample is to what extent is the rural stakeholder population, which is to say those who work to improve the lives and health of rural Americans, to what extent is that population as diverse as rural America itself? And that might be something we really pursue in follow-up work, but sort of echoing Morgan, it's something we certainly strive for and we're happy with where we landed, but we recognize that there are some clear limitations to where we ended up.

Thinking forward to Rural Healthy People 2040, one of the things we're really interested in is pursuing more direct partnerships, especially early on. To the extent we can, we'd like to partner with some of those organizations that are representing underrepresented groups in rural America early on and get their buy-in so that they can distribute the survey. I think we're also really interested in attending as many rural health meetings as we can, whether those be national meetings or regional meetings, to try and identify stakeholders in states that have been historically underrepresented in Rural Healthy People to get them on board for the next iteration.

Andrew Nelson: So as we said before, Rural Healthy People grew out of the Healthy People initiative, but Rural Healthy People doesn't really have an urban counterpart. Are there any differences or concerns you've identified that are different between rural and non-rural areas?

Timothy Callaghan: Yeah, so this has been a topic that, that we're really interested in. I think we would love to see an urban comparison to Rural Healthy People, sort of like “Urban Healthy People,” would be a really fascinating companion piece to the work that we've done on the rural side, because there are certain health issues where the concerns might be unique to urban America, right? There are certainly different challenges you face in urban communities as opposed to rural communities. With that said, when you look at research that our research team has done over the past several years for the Federal Office of Rural Health Policy, and you look at other work that's been done, published in journals like Health Affairs or for the past several years, what you consistently see when you track those urban versus rural outcomes for Healthy People objectives, specifically tied to Healthy People 2020, is that rural communities are faring worse than urban communities on almost every single objective.

It's not universal by any means, but on most of those issues, rural America is where the real struggle is. I think it's not to say that urban communities aren't struggling in certain capacities. There are certain issues that are true across the board. Real problems like the opioid epidemic or suicide in this country are examples of issues that are prominent in both rural and urban communities. But, there are other topics where rural communities are really, really struggling. But to have a true understanding of the impact of Healthy People for rural versus urban, it would be wonderful to have an urban comparison to go along with that.

Morgan Kassabian: I couldn't agree more. It would be so interesting to see the ranked priorities and how they differ across geographies. You think about access and quality as being a major differentiator between urban and rural areas, where rural areas have been experiencing rural hospital closures at an alarming rate. So it would be interesting to see, do urban folks, does access even hit their top 10? But without a companion piece, we can't know.

Andrew Nelson: For sure. You mentioned how a lot of this research was taking place during the pandemic. Did you get into specific health concerns you'd found were exacerbated by the pandemic?

Timothy Callaghan: Yeah, and I think that's a really interesting question. Inherently, we're looking on sort of a 10-year time horizon. So it's difficult to say for sure what impact the pandemic had. I think the fact that mental health and addiction were so high on the priority list suggests that those were real concerns. And we do know some individuals had issues with mental health over the course of the pandemic. We also know that the opioid epidemic got worse over the course of the pandemic. It's also worth noting that economic stability and obesity and nutrition were also in the top 10, and economic stability was a real concern during the pandemic, and individuals had issues with nutrition and obesity. So all of those that suggested the pandemic could have had a role. Interestingly though, priorities which you might have expected to make the top lists of priorities like vaccination or infectious disease didn't even crack the top 20. So it's really difficult to truly parse out the impact of the pandemic, because on the one sense, the things that are in the top 10 list suggest the pandemic really mattered, but other things they might have expected to matter didn't.

Morgan Kassabian: Yeah, I'd agree. When you read through the list, you can see an absence of knowing that we were doing fielding the survey during the pandemic you see things like child and adolescent development and workforce, and you feel this makes sense for rural America, but then with the lens of this being billed during the pandemic, you can start to see how they may have been made worse, and maybe that's why they are in the top 20.

Andrew Nelson: Yeah. Tim, earlier, I think you mentioned how as the initiative has gone on, as time has passed, some of the social determinants of health have been made more granular. In 2020, social determinants of health was just a single priority, and for Healthy People 2030, that category was broken up into five separate priorities. Why was that done, and how do those different social determinants rank in your results that you got?

Morgan Kassabian: Well, it's tough to say for sure because it was Healthy People, the broader initiative, that made the breakout. But if history tells us anything, it's that this expansion reflects the growing importance of social determinants of health in and growing level of concern in these priorities. And so while social determinants of health debuted in the top 20 list in Rural Healthy People 2020, one of the components, economic stability, rose to the top 10 this year. So again, rural Americans or rural health stakeholders are recognizing that these priorities are essential to tackle coming down.

Timothy Callaghan: Yeah, and I would add to that the growing importance of social determinants of health within the Healthy People framework, going from one priority to five, I think it very much reflects public health as a field's growing interest in the social determinants of health and growing understanding of the need to go upstream to try and understand what's impacting health outcomes. So that's likely part of the root cause. But what went into the specific decisions you'd have to ask the individuals involved at the federal level. But in terms of Rural Healthy People, you know, we found that several of them mattered, right? Healthcare access was actually categorized as a social determinant of health, and so was economic stability as, as Morgan mentioned. And then education, access and quality was also voted as quite important among rural stakeholders. So we're, we actually found that several of those priorities were important to rural stakeholders with access and stability is particularly important.

Andrew Nelson: Are there any other concerns that haven't specifically been examined up to this point that you think you might be interested in learning more about in the future?

Timothy Callaghan: Yeah, so in terms of future iterations, I think we're interested in a couple different things. I think we're interested in first trying to get a better sense of how our results might vary within rural. I think for better or worse past iterations of rural, the people have treated rural America as sort of a monolith, but we have to recognize there's a lot of diversity within rural America in terms of different regions and different racial and ethnic groups, levels of education. And we start to tease some of that apart in the policy brief we did for the Federal Office of Rural Health Policy this decade. But I think we could build on that more. We also are really interested in comparing Rural Healthy People, what would be 2040, to additional comparison groups. Urban versions of Healthy People would be really interesting.

We've also, within the Southwest Rural Health Research Center, had some interesting conversations with folks interested in border/non-border comparisons for Healthy People. So those are potential paths forward. And I, I think we're really just interested above all else in seeing how things continue to evolve over time. Right, so now that the social determinants of the health are included, how does that evolve? You could also point to the fact that the political determinants of health appear to be becoming more important as more and more public health becomes politicized. So perhaps there's an element of the political determinants of health in the next iteration as well.

Morgan Kassabian: Yeah, something that we've talked about before, and that I find really interesting, is we're surveying rural health stakeholders, but these stakeholders could reside in an urban area or they could reside in a rural area. So are there differences and responses depending on where you live? Of course, all of our participants are stakeholders and they are intimately aware of what's going on in a rural area, but potentially there are some differences there, whether or not you really reside.

Timothy Callaghan: I think one thing we would add is that in addition to this federal policy brief that was just published and is available on the Rural Health Research Gateway, the Southwest Rural Health Research Center is actually working on a very detailed, I guess you would call it an edited volume or book, focused on Rural Healthy People 2030, where we're going to take on the top 20 priorities within Rural Healthy People 2030 and write a chapter on each of them. So to really breaking down chapter by chapter what's going on with each priority, what's the background on that topic? What have we found related to that? What potential paths forward are there to make sure that rural America achieves the same outcomes as urban America over the next decade on those important priorities?

Morgan Kassabian: I would agree. I would say, one thing that I would add is even though this is a rural-focused product, I think that the use of this product is broader. Especially when you think about things like rural hospital closures and how urban hospitals are having to see more rural patients. A publication like this that is so condensed and high level is helpful in kind of understanding the needs of the rural population in a way that can be quickly taken in and then integrated into those strategic planning efforts and into making priorities for a year. So I'm excited. I think it's a publication that could be useful to a broader audience.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke to Dr. Timothy Callaghan and Morgan Kassabian. Look in our show notes for more information about their work, and visit ruralhealthinfo.org for all things pertaining to rural health.