Chapter 29 Issues with Rural, Migrant, and Urban Health Care

1. Chapter 29Issues with Rural, Migrant, and Urban Health Care

2. Definitions of Rural • Census definition: all territory, population, and housing units located outside urbanized areas and urban clusters • Office of Management and Budget definition: metropolitan and micropolitan statistical areas • U.S. Department of Agriculture definition: <2,500 residents and area classified as “completely rural” • Text definition: communities with <10,000 residents and a county population density of <1,000 persons/square mile

3. Population Statistics • Population tripled since mid-1800s to 2000; proportion of persons living in rural communities decreased from 85% to 21% • Highest rural population in the South • Changing patterns of migration • Out-migration (residents moving out of rural communities into urban places) • In-migration (during first half of 1990s; increase in residents moving into rural communities)

4. Population Characteristics • Age and gender: increasing elderly population; shifting to female-dominated rural population • Race and ethnicity: less racial diversity • Education: generally lower educational attainment • Income, housing, and jobs: average income lower than urban communities; housing quality; fewer job opportunities

5. Rural Health Issues • Agriculture and health: direct and indirect effects • Built environment (development of housing, highways, shopping areas, and other manmade features added to natural environment; urban sprawl) • Self, home, and community care: cost, travel, weather, and distance as barriers to obtaining health services; self-management of health problems • Access to acute care

6. Question Is the following statement true or false? • Rural populations are becoming more male-dominated.

7. Answer • False • There is a shift from a male-dominated to a female-dominated rural population.

8. Major Health Problems • Cardiovascular disease • Diabetes • HIV infection

9. Access to Care • Insurance, managed care, and health care services: • Historically, fee for service • Use of family practice clinics • Rural health clinics • Typically lack of core health services • Heavy reliance on public health department services

10. Access to Care (cont.) • Barriers • Physical distance • Transportation • Unpredictable weather • Limited choice of health care providers • Approaches to improve access • Mobile clinics • School-based clinics • Telehealth

11. Healthy People 2010 • Goals: increase quality and years of healthy life; eliminate health disparities • Development of Rural Healthy People 2010: A Companion Document to Healthy People 2010 • Top priorities: access to care, heart and stroke, diabetes, oral health, tobacco use, substance abuse, maternal, infant, and child health, nutrition and overweight, cancer

12. Historical Background of Migrant Workers • Legislation • The Bracero Agreement of 1942 enabled Mexicans to enter the United States for up to 6 months to provide agricultural assistance to farmers. • Migrant Health Act of 1962 authorized delivery of primary and supplementary health services to migrant farmworkers.

13. Demographic Patterns of Migrant Workers • Mobile population with shifting numbers • Estimated at 3 to 5 million • Average age of 31; half under age 29 • 80% male; 84% speak Spanish • Median education: sixth grade • Income derived primarily from work in agriculture

14. Question Is the following statement true or false? • Most migrant workers have at least an eighth-grade education.

15. Answer • False • The median educational level is the sixth grade.

16. Demographics and Lifestyle • Seasonal farmworker • Live in one geographic location and labor in the fields of that particular area • Migrant farmworker • Streams follow flow of work • Sunrise to sunset 6 days a week • Some groups use crew leaders to act as mediator with farmers • All family members work in the fields

17. Migrant Hero • Cesar Chavez • Founded National Farm Workers Association, later changed to United Farm Workers • Organized strikes and boycotts (California grapes) • Efforts united people who had no significant power

18. Health Risks of Migrant Workers and Their Families • Occupational hazards • Pesticide exposure • Substandard housing, crowding • Poor sanitation

19. Migrant Family Health • Issues • Children educationally, socially, and physically disadvantaged • Fragmented health care • Migrant adolescents more likely to abuse substances • Exposure to violence • Infectious disease • Economic barriers and limited health resources

20. Role of CHN • Improving existing services • Advocating and networking • Practicing cultural sensitivity • Using lay personnel for community outreach: promotoras, doulas • Using unique methods of health care delivery • Employing information tracking systems

21. Urban Health • Characteristics of environment related to health of the population living in large cities • Lack of connectedness in urban life • Lower overall levels of trust • Weaker family and community ties • Historically, increased population density due to immigrants • Ghettos: thickly populated sections of cities inhabited by members of same minority group • Families eventually leaving ghetto; beginning of suburbs

22. Question Which of the following reflects the health of migrant families? • Coordinated care • Wide-ranging health resources • Exposure to violence • Increased social opportunities

23. Answer c. Exposure to violence • Many migrant families are exposed to violence. The children may be educationally, socially, and physically disadvantaged. Health care is fragmented and there are limited health resources.

24. Urban Populations and Health Disparities • Rapid development of urban slums • Income gap between city and suburban residents • Poverty two times greater in cities • Overcrowding and poor-quality housing leads to poor mental health, developmental delay, and shorter stature • Violence • Employment • Shift in political power; decline in money to cities

25. Sustainable Communities • Healthy places where: • Natural and historic resources are protected • Employment is available • Urban sprawl is contained • Neighborhoods are safe • Lifelong learning is promoted • Health care and transportation are easily accessible • All citizens have opportunity to improve quality of life

26. Social Justice and CHN • Social justice: society provides for health needs and health care issues of all by treating people fairly regardless of where they live or who they are • Foundation of public health nursing • CHN practicing social justice: • Broad holistic views of health • Strong convictions about health care as a basic human right • Improving the health of communities is a societal responsibility • Concepts of inclusion, participation, empowerment, recognition that diversity is a strength, not a limitation

27. Roles of Rural CHN • Advocate • Coordinator/case manager • Health teacher • Referral agent • Mentor • Change agent/researcher • Collaborator • Activist

28. The Urban CHN • Forging working relationships • Acting as a resource • Detecting/asking the next question (listening to more than what is said) • Making informed judgments • Managing a sense of time (long-term commitments) • Teaching • Intervening with conditions influencing health • Using physical dexterity

29. Question Is the following statement true or false? • An urban community health nurse must work within the realm of shortened time commitments.

30. Answer • False • An urban community health nurse needs to be able to manage a sense of time -- that is, an awareness of the long-term commitment to the client and community.

31. Commonalities: Rural and Urban CHNs • Performing reflective self-assessment • Improving access through advocacy and bridging activities • Strengthening communities

32. Internet Resources • Bureau of Primary Health Care: Migrant Health Program: http://bphc.hrsa.gov/ • Johns Hopkins Urban Health Institute: http://www.jhsph.edu/urbanhealth/ • Migrant Clinicians Network: http://www.migrantclinician.org • National Center for Farmworker Health, Inc.: http://www.ncfh.org • National Rural Health Association: www.nrharural.org • Rural Nurse Organization: www.rno.org/index.htm