Question

How is practicing health care and public health different in rural areas than in urban areas?  What do you think would be the most effective way to retain healthcare workers in rural areas?

Answer 1

The rural population is consistently less well-off than the urban population with respect to health. Differences between the two populations are not always substantial, however. The rural population is more likely to engage in risky health-related behaviors and to experience higher rates of chronic conditions and activity limitations. Rural residents are also more likely to be uninsured for longer periods of time, and are less likely than urban residents to receive some types of health care, including tests for various chronic conditions. Limited access to health care in rural areas is generally associated with the fact that there are fewer providers. This Profile compares people who live in a metro-politan statistical area (MSA) to those who do not (non-MSA). People who reside in a MSA are referred to as urban residents and those who live in a non-MSA are referred to as rural residents. About one-fifth of the U.S. population resides in a rural area. Larger differences between the rural and urban populations may be masked as a result of the way the data are reported. The use of broad "urban" and "rural" categories may mask some differences because of the substantial variations in population size and density. For example, a rural area may refer to a county with a city of 10,000 or more, or to a frontier area which has an extremely low population density, usually fewer than 6 people per square mile.

Urban Context
The social environment: Urban environments are more likely to see large disparities in socioeconomic status, higher rates of crime and violence, the presence of marginalized populations (e.g., sex workers) with high risk behaviors, and a higher prevalence of psychological stressors that accompany the increased density and diversity of cities.

The physical environment: In densely populated urban areas, there is often a lack of facilities and outdoor areas for exercise and recreation. In addition, air quality is often lower in urban environments which can contribute to chronic diseases such as asthma. In the developing world, urban dwellers often live in large slums which lack basic sanitation and utilities such as water and electricity. Lack of basic infrastructure can exacerbate rates of infectious disease and further perpetuate the cycle of poverty.

Access to health and social service: Persons of lower socioeconomic status and minority populations are more likely to live in urban areas and are more likely to lack health insurance. Thus, these populations face barriers to care, receive poorer quality care, and disproportionately use emergency systems. Other commonly represented populations in cities are undocumented immigrants and transient populations. The high prevalence of individuals without health insurance or citizenship creates a greater burden on available systems. This often leads to vast disparities in health care outcomes as well as a two-tiered health care system where insured individuals have access to preventive and routine health care while marginalized populations utilize “safety-net” emergency room care.

Rural Context
The social environment: In the United States, rural elders have significantly poorer health status than urban elders. Also, rural residents smoke more, exercise less, have less nutritional diets, and are more likely to be obese than suburban residents. “Health educators are increasingly aware of the need for culturally sensitive approaches to modifying unhealthy behavior, but few rural health researchers and policymakers are asking the relevant cultural question, ‘Why does rural residence (culture, community, and environment) reinforce negative health behaviors?’ ” In fact, many of the major public health problems faced in rural areas (e.g., obesity, tobacco use, failure to use seat belts) are not likely to respond to an increased presence of general practitioners, physician specialists, or physician extenders. Instead, these challenges call for a social perspective with a focus on prevention and a healthy lifestyle.

Despite negative health behaviors, many aspects of rural social life contribute to positive health outcomes. “Rural areas frequently have strengths including dense social networks, social ties of long duration, shared life experiences, high quality of life, and norms of self-help, and reciprocity”. Addressing the needs of rural areas requires building upon the positive aspects of rural life while addressing the health, public health, infrastructure, and economic needs of rural areas.

Similar issues exist in the developing world. A recent World Bank report “Las Casas Maternas en Nicaragua” reported that 60% of adolescent pregnant women are from rural areas. The problem of youth pregnancy stems from the larger issues of rural versus urban access to education, health services, and employment. Furthermore, rural areas in Nicaragua have higher levels of unemployment and poverty, and lower levels of education. The national average of people without adequate education is 18% while in rural areas that number jumps to 25%.

The physical environment: Rural women in the United States, especially less educated women, are more sedentary than urban women. Rural individuals are less likely to report sidewalks, streetlights, high crime, access to facilities, and frequently seeing others exercise in their neighborhood. While poor air quality and crime rates are likely to be less of an issue in rural areas, insufficiencies in the built environment make it difficult for rural residents to exercise and maintain healthy habits.

Access to health and social service: Evidence indicates that rural residents have limited access to health care and that rural areas are underserved by primary care physicians. In the developing and developed world, many rural individuals must travel substantial distances for primary medical care, requiring significantly longer travel times to reach care than their urban counterparts. Furthermore, some rural areas have a higher proportion of uninsured and individually insured residents than urban areas.

A manager/supervisor, there are simple, yet powerful actions you can take to influence job satisfaction, morale, and productivity.

• Treat people with courtesy, politeness, and kindness.
• Maintain open communication and encourage staff to express their opinions and ideas.
• Listen to your staff and try to respond to their requests.
• Implement policies and procedures consistently and fairly.
• Include staff in meetings, discussions, trainings, and events.
• Make staff meetings a time to celebrate.
• Give employees their birthday off.
• Give staff some time off (hours, half day, full day) as an incentive for doing something special/extra.
• Spend time with employees. Involve employees in determining their career path goals and development plan. Provide opportunities for training and professional development.
• Provide opportunities for advancement.
• Coach employee skill development.
• Praise more than you criticize and encourage praise among coworkers.
• Foster teamwork. When employees work toward a common goal, performance improves.
• Lead by example. Lead from Mission and Vision.
• Delegate. Employees want job autonomy. Help establish goals for your department and work unit.
• Set understandable expectations and goals for each staff member. Communicate them in a clear, concise manner.
• Manage gossip. Otherwise, interpersonal relationships can be damaged, thus ` disrupting employee motivation and morale.
• Create a culture of accountability. At meetings have an agenda; start and end on time, and follow-up.
• Create a motivating workplace. Integrate values such as integrity, empowerment, perseverance, equality, discipline, and accountability into the organization.
• Think positive! There’s a lot of power in optimistic thinking.
• Let staff know they matter and make a difference.
• Utilize your staff’s talent and skills. Avoid burnout. Give workers added responsibilities, new challenges, and advancement opportunities.
• Say thank you. Give them a card of thanks in your own handwriting.
• Respect the work/life balance.
• Laugh. Have some fun. Laughter contributes to positive morale, a major factor in retaining valued employees.
• If applicable – cover a group for your employee so he/she can "catch up" with paperwork.
• Have a "spring cleaning" day when staff can have a day off from their typical schedule to clean up their work space – and/or catch up on paperwork.
• Implement their ideas.
• Involve them in committees to be a "leader" in something they are interested in and knowledgeable.
• Make clinical supervision a weekly priority which can only get cancelled in emergencies.
• Get to know your employees. Ask them (safe) personal questions about their family life, hobbies and interests
• Know it is your duty as their manager/supervisor to give your staff the care, tools, and resources they need to be successful.
• REFLECT: What am I doing to take care of and give my staff these things?

Hiring and keeping the best health care professionals means creating a talent plan to reenergize and refocus your management team. Health care organizations must attract and retain qualified clinical professionals to ensure quality care. They must constantly monitor their employee value proposition. They must source and develop talent carefully, keeping employees engaged and committed, while removing underperformers. And they must ensure that every manager in the health care organization understands the rules of engagement and embraces a leadership role in talent management.