- Email: [email protected]
Rural women’s health: A research agenda for the future
Women’s Health Issues 15 (2005) 200 –203
COMMENTARY
RURAL WOMEN’S HEALTH: A RESEARCH AGENDA FOR THE FUTURE Luanne E. Thorndyke, MD, FACPⴱ Penn State College of Medicine, Hershey, Pennsylvania
T
he interrelationship between mental and physical health, and between mental health and behavioral health, links closely to the overall health of communities: in this regard, the health of rural America is at risk. Rural residents have higher rates of chronic illness, life-threatening medical conditions (such as motor vehicle accidents), greater environmental hazards, and increased overall age-adjusted mortality (Braden & Beauregard, 1994). Mental health issues, and medical–psychiatric comorbidities are among the most prominent health issues of rural residents (Braden & Beauregard, 1994; Wagenfeld et al., 1993; Robertson et al., 1997). At least 15 million rural residents, women and men, suffer with significant mental illness, substance abuse/dependence, and medical–psychiatric comorbidities (Wagenfeld et al., 1993). Finding solutions to the difficulty of providing mental health services for rural populations, preventing comorbidity, disability and other consequences of mental illness is a significant rural—and national—policy need. Health data and information that focus exclusively on rural women’s health issues and in particular rural mental health services research are limited. Although evidence suggests that the prevalence of mental illness (mood, anxiety, cognitive, developmental, and psychotic disorders) is similar in urban and rural areas (Wagenfeld et al., 1993), the number of providers is not, so that access to professional help for women living in rural areas is a significant concern. Problems related to alcohol use and rates of fetal alcohol syndrome are particularly significant among rural women (Wagenfeld et al., 1993; Robertson et al., 1997). Ac-
ⴱ Correspondence to: Luanne E. Thorndyke, Associate Dean for Professional Development, Associate Professor of Medicine, Penn State College of Medicine, 500 University Drive, MC-H117, Hershey, PA 17033; Phone: 717-531-1101; Fax: 717-531-4582. E-mail: [email protected] Copyright © 2005 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
cording to the National Institute on Alcohol Abuse and Alcoholism, rural children top the geographical list of those exhibiting several major risk behaviors for alcohol abuse. Rural suicide rates are higher than urban suicide rates (Wagenfeld et al., 1993). Rural residents who are women, poor, elderly, or of minority racial or ethnic status are especially at risk for significant mental illness (Braden & Beauregard, 1994; Robertson et al., 1997; Wagenfeld et al., 1993). A number of barriers to the use of mental health services and to use of alcohol services (Booth & Mclaughlin, 2000) have been identified. These include lack of ability to pay for services, decreased likelihood of insurance plans including coverage for mental health services, government funding decisions and priorities, disparities in health care providers including mental health care providers, and cultural barriers to accessing mental health services such as the stigma associated with having a mental health problem and negative labeling of those who receive treatment for mental health problems. Rural cultural values, including self-sufficiency and a reluctance to seek medical care unless seriously ill, may influence a rural woman’s decision to utilize health care services. The lack of anonymity often present in small, close-knit rural communities may negatively impact women who then choose not to seek assistance in situations involving domestic violence, substance abuse, or mental illness.
Key Considerations in Rural Women’s Health Rural women’s health is a relatively new focus in the research arena. Rural woman is as complicated as a patchwork quilt that metaphorically symbolizes her being. Women who live in a rural environment are not a homogeneous group. They represent every ethnic, 1049-3867/05 $-See front matter. doi:10.1016/j.whi.2005.07.004
L. E. Thorndyke / Women’s Health Issues 15 (2005) 200 –203
cultural, and socioeconomic group. They are of all ages, but increasingly, and disproportionately, old. Although rural women represent approximately 30% of the women living in the United States, they are scattered throughout every state in the country. As demonstrated in the article by Pullen et al. (2005), there are differences among the subpopulations of rural women even in the amounts and types of food consumed by normal weight, overweight, and obese rural women as well as in cardiorespiratory fitness. Key methodologic issues in defining and measuring rurality must be considered when designing research on rural women. Demographers, epidemiologists, and policymakers have not applied consistent definitions to the categorization of rural. As future research is undertaken, there is a clear need to further define rural and to standardize the definitions of this and related terms including frontier, semirural, semiurban, nonurban, metropolitan, and nonmetropolitan. In addition, vigorous research needs to be done to enhance existing databases and to develop new datasets that reflect the more refined rural categories. Once demographic differences have been more completely described through additional research, a much deeper analysis of the variables causing health differences can be probed. The result will be a greater understanding of the impact of rural status on health and disease in women. There is a significant need to greatly expand epidemiologic and social science research related to defining and understanding ethnic and cultural differences, regardless of residence. With the recent focus on health disparities and health disparities research, a rich new source of information should be forthcoming. However, additional research is needed to evaluate ethnic and cultural differences among women as they relate to residential location (rural versus urban). How are the health disparities that exist between ethnic groups impacted by residence? Why do rural women suffer higher rates of chronic illness and greater morbidity from chronic diseases? The potential double jeopardy faced by rural minority women, suggested in epidemiologic breast cancer research (Lannin, Mathews, Mitchell, Swanson, & Edwards, 1998; Amey, & Miller, 1997) needs greater focus to tease out the interaction, and the extent of interaction between race and residence. A complete understanding of the health of rural women (and of women in general) is not possible without a clear linkage and integration of the biopsychosocial model of health and disease. Not surprisingly, Lannin et al. (1998) found racial differences (being African American) and major socioeconomic influences (such as low income, no private health insurance) were significant predictors of late-stage presentation of breast cancer. Of importance, however, cultural beliefs held by African American
201
women in rural North Carolina proved to be significant predictors of advanced stage breast cancer at presentation (Lannin et al., 1998). Others (Hauenstein, 2003) have cited the need for ethnographic studies to gain greater understanding of the cultural factors associated with health problems such as major depressive disorder and its treatment. Clearly, further study needs to be undertaken to explore the effects of urban and rural residence, race, ethnicity, economic status, and cultural beliefs on health and disease. Additional delineation and description of the behavioral factors that provide strength and support to rural women may provide information to help rural women in their communities. Identifying the factors that positively impact a woman’s physical and emotional well-being—factors such as close relationships, strong ties to extended family, spiritual wellness— may provide rural women with strategies and mechanisms to better manage the multiple stressors and challenges of rural life. Black, Cook, & McBride (2005) describe the impact of a positive intimate relationship, as well as strong community support, in this issue. The extended network of support systems is particularly important for women who do not have a positive intimate relationship (Black et al., 2005). Can these findings be generalized to other rural subpopulations beyond the rural African American partnered community? Other studies have suggested that the closeness of the rural community contributes to a loss of privacy and concerns about confidentiality that can be an obstacle to obtaining health services, particularly for issues such as substance abuse, domestic violence, and mental health problems. Further research efforts might explore the delicate balance in rural communities between providing social support leading to positive health outcomes versus concerns of privacy and stigmatization providing an obstacle to accessing needed care. How can these social networks be reached and what are the health education needs of these communities? Mental health services research is an area that needs a greater focus on rural women. The National Centers of Excellence in Women’s Health (CoEs) have become a wonderful living laboratory to study a new concept in the delivery of health services to women: comprehensive, integrated care through a single point of service. It is gratifying that the National CoEs, located in academic health centers across the nation, have been shown to provide a high quality of primary care, higher than that received in comparison community samples (Anderson et al., 2002). The results of the CoEs in mental health service delivery for rural women are, however, somewhat disappointing. Only 4 of the 19 CoEs seemed to identify rural women as a part of the targeted population. Yet none of the CoEs offered mental health services specifically targeted to
202
L. E. Thorndyke / Women’s Health Issues 15 (2005) 200 –203
rural women (Hillemeier et al., 2005). The dependence on primary care providers to identify and treat mental health conditions is the current standard of care for the vast majority of rural women. What can be done at the national and policy levels to stimulate interest and provide outreach to meet the needs of rural women? The multitude of issues that impact the mental health of rural women are both similar and different from urban women. Increased knowledge regarding specific issues such as depression, anxiety, alcohol problems, and domestic abuse for women in rural areas, particularly about gender-specific barriers to obtaining services and gender-specific needs for particular services, is needed (Booth & Mclaughlin, 2000). The solutions to the problems of access, availability of mental health care, availability of specialty services, community support services, and financing of mental health care services, however, will be distinctly rural in design. The role of nonphysician health care providers (Hauenstein, 1996) and nonprofessional personnel (Hauenstein, 2003) in the delivery of mental health services for rural women deserves systematic research evaluation to determine efficacy. The contribution of the environment, broadly defined, is an important consideration that has not yet been sufficiently examined. Environmental issues that need further evaluation include occupational toxin exposures (herbicides, pesticides, and other chemical agents), air/water impact of factory farms, traumatic injury, and occupation-related disability. The Iowa Women’s Health Study (Folsom et al., 1996) studied a large, population-based cohort of middle-aged women residing on farms in Iowa to determine whether site-specific cancer incidence is different among farm women versus those living elsewhere. How can research on rural specific issues such as environmental exposure and traumatic injury be promoted? The use of computers and Internet access to health education and resources needs greater study to determine the impact on the risk status and health of various populations, including rural women. The successful incorporation of telecommunications technology to deliver diabetes education and social support to rural women in Montana and surrounding states has been demonstrated to positively influence measures of social support and quality of life (Smith & Weinert, 2000). In this issue of Womens Health Issues, Weinart and Hill show that computer-based health information technologies have great promise for helping rural women to obtain health information, and to decrease their sense of geographical and personal isolation (Weinhart & Hill, 2005). How do women utilize Internet-based health information? Does increased ability and use of Internet-based health resources lead to improved health outcomes? Healthy People 2010 (Department of Health and
Human Services, 2000) established a national health objective to improve health literacy by the end of the decade. Health literacy, as defined by the Department of Health and Human Services, is the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions and to use the information and services to enhance health. The use of technology is a logical mechanism that must be harnessed to bring the world of health information resources to the lives of women living in isolated rural environments. To what extent will rural women who are capable of accessing the internet to obtain health information utilize this resource, and what will be the impact of this capability? It is expected that greater access to health information will improve the overall health of rural women, but this hypothesis remains unproven. As technology advances into the schools, libraries, and homes of rural residents, the connection to information and resources may improve the lives and health of those in otherwise isolated rural environments. Future studies will need to evaluate the impact of greater use of technology on overall health status in rural women. Even more important, however, is the need to reach isolated populations with information that can be understood and applied by the user. How can technology assist poorer, less educated women who are disadvantaged not only by a rural geographic location, but also by socioeconomic or educational status? What outreach mechanisms are needed to overcome the adverse consequences of low health literacy? Technology will also provide greater support to isolated rural health care practitioners in manpower shortage areas. Additional efforts need to be devoted to the factors necessary to attract, support, and retain rural health care service providers. What applications of telehealth and telemedicine technology will result in greater access to services and improved health outcomes?
A Research Agenda for the Future Although a number of research questions have been identified throughout this commentary, I propose that the future research agenda for rural women’s health be grouped in several thematic areas: •
•
Health differences and diversity: Continued research is needed to define and understand the differences (and commonalities) among urban and rural women, and among various subpopulations of rural women. Health disparities and rural health: The current focus on health disparities research needs to be expanded to include the differences in health and disease experienced as a result of place of residence (urban or rural). Efforts to reduce health disparities among various
L. E. Thorndyke / Women’s Health Issues 15 (2005) 200 –203
•
•
ethnic populations should be expanded to include health disparities found in rural populations. Health literacy among rural women: There is a clear need to understand the nature and extent of the health literacy problem in rural women and to develop interventions to address the problem and improve health outcomes. Technology-based interventions to develop skills in utilizing the computer to access health information hold great promise for isolated rural women and their families. Inclusion of rural women in clinical research: Are the results of clinical trials applicable regardless of residential environment? Outcomes-based research must be performed to evaluate the efficacy of rural implementation of social programs and interventions designed for use in more urban settings. McKinney (1998), in her study on service needs of rural women with HIV/AIDS, suggests a need for new kinds of rural initiatives that embed HIV prevention and care into broader programs of educational and economic development. Hillemeier et al. (2005) conclude that the CoEs would be good sites to develop and test mental health outreach services for rural women.
Clearly, much more research is needed to identify the optimal methods to translate the knowledge gained from basic and clinical research into clinical practice in the rural environment, as well as outcomesbased research on clinical application and effectiveness in the rural environment.
References Amey, C., & Miller, M. (1997). The role of race and residence in determining stage at diagnosis of breast cancer. The Journal of Rural Health, 13 (2), 99 –108. Anderson, R. T., Weisman, C. S., Scholle, S. H., Henderson, J. T., Oldendisk, R., & Camacho, F. (2002). Evaluation of the quality of care in the clinical care centers of the National Centers of Excellence in Women’s Health. Women’s Health Issues, 12 (6), 309 –326. Black, A. R., Cook, J. L., & McBride Murry V. (2005). Ties that bind: Implications of social support for rural, partnered African Amer-
203
ican women’s health functioning. Women’s Health Issues, 15(5), 216 –223. Booth, B. M., & Mclaughlin, Y. S. (2000). Barriers to and need for alcohol services for women in rural populations. Alcoholism: Clinical & Experimental Research 24(8), 1267–1275. Braden, J., & Beauregard, K. (1994). Health status and access to care of rural and urban populations. National Medical Expenditure Survey Research Findings 18. Rockville, MD: Agency for Health Care Policy and Research. Department of Health and Human Services. (2000). Healthy People 2010 (Vol 1). McLean, VA: International Medical Publishing. Folsom, A., Zhang, S., Sellers, T. A., Zheng, W., Kushi, L. H., &Cerhan, J. R. (1996). Cancer incidence among women living on farms: Findings from the Iowa Women’s Health Study. Journal of Occupational & Environmental Medicine, 38 (11), 1171–1176. Hauenstein, E. J. (1996). Testing innovative nursing care: home Intervention with depressed rural women. Issues in Mental Health Nursing, 17 (1), 33–50. Hauenstein, E. J. (2003). No comfort in the rural South: Women living depressed. Archives of Psychiatric Nursing, 17 (1), 3–11. Hillemeier, M. M., Weisman, C. S., Baker, K., & Primavera, K. (2005). Mental health services provided through the National Centers of Excellence in Women’s Health: Do they reach rural women? Women’s Health Issues, 15(5), 224 –229. Lannin, D., Mathews, H., Mitchell, J., Swanson, M. S., & Edwards, M.S. (1998). Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. The Journal of the American Medical Association, 279, 1801–1807. McKinney, M. M. (1998). Service needs and networks of rural women with HIV/AIDS. AIDS Patient Care STDS, 12 (6), 471– 480. Pullen, C. H., Walker, S. N., Hageman, P. A., Boeckner, L. S., & Oberdorfer, M. K. (2005). Differences in eating and activity markers among normal weight, overweight, and obese rural women. Women’s Health Issues, 15(5), 209 –215. Robertson, E. B., Sloboda, Z., Boyd, G. M., Beatty, L., & Kozel, N. J. (Eds). (1997). Rural substance abuse: State of knowledge and Issues. Rockville, MD: National Institute on Alcoholism and Alcohol Abuse. NIDA Research Monograph 168. Smith, L., & Weinert, C. (2000). Telecommunication support for rural women with diabetes. The Diabetes Educator, 26 (4), 645– 655. Wagenfeld, M. O., Murray, J. D., Mohatt, D. F., & DeBruyn, J. C. (1994). Mental health and rural America: 1980 –1993: An overview and annotated bibliography. Rockville, MD: National Institute of Mental Health, Office of Rural Health Policy. Weinhart, C., & Hill, W.G. (2005). Rural women with chronic illness: Computer use and skill acquisition. Women’s Health Issues, 15(5), 230 –235.
COMMENTARY
RURAL WOMEN’S HEALTH: A RESEARCH AGENDA FOR THE FUTURE Luanne E. Thorndyke, MD, FACPⴱ Penn State College of Medicine, Hershey, Pennsylvania
T
he interrelationship between mental and physical health, and between mental health and behavioral health, links closely to the overall health of communities: in this regard, the health of rural America is at risk. Rural residents have higher rates of chronic illness, life-threatening medical conditions (such as motor vehicle accidents), greater environmental hazards, and increased overall age-adjusted mortality (Braden & Beauregard, 1994). Mental health issues, and medical–psychiatric comorbidities are among the most prominent health issues of rural residents (Braden & Beauregard, 1994; Wagenfeld et al., 1993; Robertson et al., 1997). At least 15 million rural residents, women and men, suffer with significant mental illness, substance abuse/dependence, and medical–psychiatric comorbidities (Wagenfeld et al., 1993). Finding solutions to the difficulty of providing mental health services for rural populations, preventing comorbidity, disability and other consequences of mental illness is a significant rural—and national—policy need. Health data and information that focus exclusively on rural women’s health issues and in particular rural mental health services research are limited. Although evidence suggests that the prevalence of mental illness (mood, anxiety, cognitive, developmental, and psychotic disorders) is similar in urban and rural areas (Wagenfeld et al., 1993), the number of providers is not, so that access to professional help for women living in rural areas is a significant concern. Problems related to alcohol use and rates of fetal alcohol syndrome are particularly significant among rural women (Wagenfeld et al., 1993; Robertson et al., 1997). Ac-
ⴱ Correspondence to: Luanne E. Thorndyke, Associate Dean for Professional Development, Associate Professor of Medicine, Penn State College of Medicine, 500 University Drive, MC-H117, Hershey, PA 17033; Phone: 717-531-1101; Fax: 717-531-4582. E-mail: [email protected] Copyright © 2005 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
cording to the National Institute on Alcohol Abuse and Alcoholism, rural children top the geographical list of those exhibiting several major risk behaviors for alcohol abuse. Rural suicide rates are higher than urban suicide rates (Wagenfeld et al., 1993). Rural residents who are women, poor, elderly, or of minority racial or ethnic status are especially at risk for significant mental illness (Braden & Beauregard, 1994; Robertson et al., 1997; Wagenfeld et al., 1993). A number of barriers to the use of mental health services and to use of alcohol services (Booth & Mclaughlin, 2000) have been identified. These include lack of ability to pay for services, decreased likelihood of insurance plans including coverage for mental health services, government funding decisions and priorities, disparities in health care providers including mental health care providers, and cultural barriers to accessing mental health services such as the stigma associated with having a mental health problem and negative labeling of those who receive treatment for mental health problems. Rural cultural values, including self-sufficiency and a reluctance to seek medical care unless seriously ill, may influence a rural woman’s decision to utilize health care services. The lack of anonymity often present in small, close-knit rural communities may negatively impact women who then choose not to seek assistance in situations involving domestic violence, substance abuse, or mental illness.
Key Considerations in Rural Women’s Health Rural women’s health is a relatively new focus in the research arena. Rural woman is as complicated as a patchwork quilt that metaphorically symbolizes her being. Women who live in a rural environment are not a homogeneous group. They represent every ethnic, 1049-3867/05 $-See front matter. doi:10.1016/j.whi.2005.07.004
L. E. Thorndyke / Women’s Health Issues 15 (2005) 200 –203
cultural, and socioeconomic group. They are of all ages, but increasingly, and disproportionately, old. Although rural women represent approximately 30% of the women living in the United States, they are scattered throughout every state in the country. As demonstrated in the article by Pullen et al. (2005), there are differences among the subpopulations of rural women even in the amounts and types of food consumed by normal weight, overweight, and obese rural women as well as in cardiorespiratory fitness. Key methodologic issues in defining and measuring rurality must be considered when designing research on rural women. Demographers, epidemiologists, and policymakers have not applied consistent definitions to the categorization of rural. As future research is undertaken, there is a clear need to further define rural and to standardize the definitions of this and related terms including frontier, semirural, semiurban, nonurban, metropolitan, and nonmetropolitan. In addition, vigorous research needs to be done to enhance existing databases and to develop new datasets that reflect the more refined rural categories. Once demographic differences have been more completely described through additional research, a much deeper analysis of the variables causing health differences can be probed. The result will be a greater understanding of the impact of rural status on health and disease in women. There is a significant need to greatly expand epidemiologic and social science research related to defining and understanding ethnic and cultural differences, regardless of residence. With the recent focus on health disparities and health disparities research, a rich new source of information should be forthcoming. However, additional research is needed to evaluate ethnic and cultural differences among women as they relate to residential location (rural versus urban). How are the health disparities that exist between ethnic groups impacted by residence? Why do rural women suffer higher rates of chronic illness and greater morbidity from chronic diseases? The potential double jeopardy faced by rural minority women, suggested in epidemiologic breast cancer research (Lannin, Mathews, Mitchell, Swanson, & Edwards, 1998; Amey, & Miller, 1997) needs greater focus to tease out the interaction, and the extent of interaction between race and residence. A complete understanding of the health of rural women (and of women in general) is not possible without a clear linkage and integration of the biopsychosocial model of health and disease. Not surprisingly, Lannin et al. (1998) found racial differences (being African American) and major socioeconomic influences (such as low income, no private health insurance) were significant predictors of late-stage presentation of breast cancer. Of importance, however, cultural beliefs held by African American
201
women in rural North Carolina proved to be significant predictors of advanced stage breast cancer at presentation (Lannin et al., 1998). Others (Hauenstein, 2003) have cited the need for ethnographic studies to gain greater understanding of the cultural factors associated with health problems such as major depressive disorder and its treatment. Clearly, further study needs to be undertaken to explore the effects of urban and rural residence, race, ethnicity, economic status, and cultural beliefs on health and disease. Additional delineation and description of the behavioral factors that provide strength and support to rural women may provide information to help rural women in their communities. Identifying the factors that positively impact a woman’s physical and emotional well-being—factors such as close relationships, strong ties to extended family, spiritual wellness— may provide rural women with strategies and mechanisms to better manage the multiple stressors and challenges of rural life. Black, Cook, & McBride (2005) describe the impact of a positive intimate relationship, as well as strong community support, in this issue. The extended network of support systems is particularly important for women who do not have a positive intimate relationship (Black et al., 2005). Can these findings be generalized to other rural subpopulations beyond the rural African American partnered community? Other studies have suggested that the closeness of the rural community contributes to a loss of privacy and concerns about confidentiality that can be an obstacle to obtaining health services, particularly for issues such as substance abuse, domestic violence, and mental health problems. Further research efforts might explore the delicate balance in rural communities between providing social support leading to positive health outcomes versus concerns of privacy and stigmatization providing an obstacle to accessing needed care. How can these social networks be reached and what are the health education needs of these communities? Mental health services research is an area that needs a greater focus on rural women. The National Centers of Excellence in Women’s Health (CoEs) have become a wonderful living laboratory to study a new concept in the delivery of health services to women: comprehensive, integrated care through a single point of service. It is gratifying that the National CoEs, located in academic health centers across the nation, have been shown to provide a high quality of primary care, higher than that received in comparison community samples (Anderson et al., 2002). The results of the CoEs in mental health service delivery for rural women are, however, somewhat disappointing. Only 4 of the 19 CoEs seemed to identify rural women as a part of the targeted population. Yet none of the CoEs offered mental health services specifically targeted to
202
L. E. Thorndyke / Women’s Health Issues 15 (2005) 200 –203
rural women (Hillemeier et al., 2005). The dependence on primary care providers to identify and treat mental health conditions is the current standard of care for the vast majority of rural women. What can be done at the national and policy levels to stimulate interest and provide outreach to meet the needs of rural women? The multitude of issues that impact the mental health of rural women are both similar and different from urban women. Increased knowledge regarding specific issues such as depression, anxiety, alcohol problems, and domestic abuse for women in rural areas, particularly about gender-specific barriers to obtaining services and gender-specific needs for particular services, is needed (Booth & Mclaughlin, 2000). The solutions to the problems of access, availability of mental health care, availability of specialty services, community support services, and financing of mental health care services, however, will be distinctly rural in design. The role of nonphysician health care providers (Hauenstein, 1996) and nonprofessional personnel (Hauenstein, 2003) in the delivery of mental health services for rural women deserves systematic research evaluation to determine efficacy. The contribution of the environment, broadly defined, is an important consideration that has not yet been sufficiently examined. Environmental issues that need further evaluation include occupational toxin exposures (herbicides, pesticides, and other chemical agents), air/water impact of factory farms, traumatic injury, and occupation-related disability. The Iowa Women’s Health Study (Folsom et al., 1996) studied a large, population-based cohort of middle-aged women residing on farms in Iowa to determine whether site-specific cancer incidence is different among farm women versus those living elsewhere. How can research on rural specific issues such as environmental exposure and traumatic injury be promoted? The use of computers and Internet access to health education and resources needs greater study to determine the impact on the risk status and health of various populations, including rural women. The successful incorporation of telecommunications technology to deliver diabetes education and social support to rural women in Montana and surrounding states has been demonstrated to positively influence measures of social support and quality of life (Smith & Weinert, 2000). In this issue of Womens Health Issues, Weinart and Hill show that computer-based health information technologies have great promise for helping rural women to obtain health information, and to decrease their sense of geographical and personal isolation (Weinhart & Hill, 2005). How do women utilize Internet-based health information? Does increased ability and use of Internet-based health resources lead to improved health outcomes? Healthy People 2010 (Department of Health and
Human Services, 2000) established a national health objective to improve health literacy by the end of the decade. Health literacy, as defined by the Department of Health and Human Services, is the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions and to use the information and services to enhance health. The use of technology is a logical mechanism that must be harnessed to bring the world of health information resources to the lives of women living in isolated rural environments. To what extent will rural women who are capable of accessing the internet to obtain health information utilize this resource, and what will be the impact of this capability? It is expected that greater access to health information will improve the overall health of rural women, but this hypothesis remains unproven. As technology advances into the schools, libraries, and homes of rural residents, the connection to information and resources may improve the lives and health of those in otherwise isolated rural environments. Future studies will need to evaluate the impact of greater use of technology on overall health status in rural women. Even more important, however, is the need to reach isolated populations with information that can be understood and applied by the user. How can technology assist poorer, less educated women who are disadvantaged not only by a rural geographic location, but also by socioeconomic or educational status? What outreach mechanisms are needed to overcome the adverse consequences of low health literacy? Technology will also provide greater support to isolated rural health care practitioners in manpower shortage areas. Additional efforts need to be devoted to the factors necessary to attract, support, and retain rural health care service providers. What applications of telehealth and telemedicine technology will result in greater access to services and improved health outcomes?
A Research Agenda for the Future Although a number of research questions have been identified throughout this commentary, I propose that the future research agenda for rural women’s health be grouped in several thematic areas: •
•
Health differences and diversity: Continued research is needed to define and understand the differences (and commonalities) among urban and rural women, and among various subpopulations of rural women. Health disparities and rural health: The current focus on health disparities research needs to be expanded to include the differences in health and disease experienced as a result of place of residence (urban or rural). Efforts to reduce health disparities among various
L. E. Thorndyke / Women’s Health Issues 15 (2005) 200 –203
•
•
ethnic populations should be expanded to include health disparities found in rural populations. Health literacy among rural women: There is a clear need to understand the nature and extent of the health literacy problem in rural women and to develop interventions to address the problem and improve health outcomes. Technology-based interventions to develop skills in utilizing the computer to access health information hold great promise for isolated rural women and their families. Inclusion of rural women in clinical research: Are the results of clinical trials applicable regardless of residential environment? Outcomes-based research must be performed to evaluate the efficacy of rural implementation of social programs and interventions designed for use in more urban settings. McKinney (1998), in her study on service needs of rural women with HIV/AIDS, suggests a need for new kinds of rural initiatives that embed HIV prevention and care into broader programs of educational and economic development. Hillemeier et al. (2005) conclude that the CoEs would be good sites to develop and test mental health outreach services for rural women.
Clearly, much more research is needed to identify the optimal methods to translate the knowledge gained from basic and clinical research into clinical practice in the rural environment, as well as outcomesbased research on clinical application and effectiveness in the rural environment.
References Amey, C., & Miller, M. (1997). The role of race and residence in determining stage at diagnosis of breast cancer. The Journal of Rural Health, 13 (2), 99 –108. Anderson, R. T., Weisman, C. S., Scholle, S. H., Henderson, J. T., Oldendisk, R., & Camacho, F. (2002). Evaluation of the quality of care in the clinical care centers of the National Centers of Excellence in Women’s Health. Women’s Health Issues, 12 (6), 309 –326. Black, A. R., Cook, J. L., & McBride Murry V. (2005). Ties that bind: Implications of social support for rural, partnered African Amer-
203
ican women’s health functioning. Women’s Health Issues, 15(5), 216 –223. Booth, B. M., & Mclaughlin, Y. S. (2000). Barriers to and need for alcohol services for women in rural populations. Alcoholism: Clinical & Experimental Research 24(8), 1267–1275. Braden, J., & Beauregard, K. (1994). Health status and access to care of rural and urban populations. National Medical Expenditure Survey Research Findings 18. Rockville, MD: Agency for Health Care Policy and Research. Department of Health and Human Services. (2000). Healthy People 2010 (Vol 1). McLean, VA: International Medical Publishing. Folsom, A., Zhang, S., Sellers, T. A., Zheng, W., Kushi, L. H., &Cerhan, J. R. (1996). Cancer incidence among women living on farms: Findings from the Iowa Women’s Health Study. Journal of Occupational & Environmental Medicine, 38 (11), 1171–1176. Hauenstein, E. J. (1996). Testing innovative nursing care: home Intervention with depressed rural women. Issues in Mental Health Nursing, 17 (1), 33–50. Hauenstein, E. J. (2003). No comfort in the rural South: Women living depressed. Archives of Psychiatric Nursing, 17 (1), 3–11. Hillemeier, M. M., Weisman, C. S., Baker, K., & Primavera, K. (2005). Mental health services provided through the National Centers of Excellence in Women’s Health: Do they reach rural women? Women’s Health Issues, 15(5), 224 –229. Lannin, D., Mathews, H., Mitchell, J., Swanson, M. S., & Edwards, M.S. (1998). Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. The Journal of the American Medical Association, 279, 1801–1807. McKinney, M. M. (1998). Service needs and networks of rural women with HIV/AIDS. AIDS Patient Care STDS, 12 (6), 471– 480. Pullen, C. H., Walker, S. N., Hageman, P. A., Boeckner, L. S., & Oberdorfer, M. K. (2005). Differences in eating and activity markers among normal weight, overweight, and obese rural women. Women’s Health Issues, 15(5), 209 –215. Robertson, E. B., Sloboda, Z., Boyd, G. M., Beatty, L., & Kozel, N. J. (Eds). (1997). Rural substance abuse: State of knowledge and Issues. Rockville, MD: National Institute on Alcoholism and Alcohol Abuse. NIDA Research Monograph 168. Smith, L., & Weinert, C. (2000). Telecommunication support for rural women with diabetes. The Diabetes Educator, 26 (4), 645– 655. Wagenfeld, M. O., Murray, J. D., Mohatt, D. F., & DeBruyn, J. C. (1994). Mental health and rural America: 1980 –1993: An overview and annotated bibliography. Rockville, MD: National Institute of Mental Health, Office of Rural Health Policy. Weinhart, C., & Hill, W.G. (2005). Rural women with chronic illness: Computer use and skill acquisition. Women’s Health Issues, 15(5), 230 –235.