Online training could help rural doctors offer better mental health care

More than half of all U.S. mental health care takes place at the primary-care level, and that percentage is even higher in rural areas, where mental-health doctors are often hundreds of miles away, reports Newswise, a research-reporting service. A new online training program could help rural primary-care doctors better treat patients with mental health issues, and that could be important in Kentucky.

The Behavioral Health Education Center of Nebraska, a part of the University of Nebraska Medical Center, designed the program. Educational Director Howard Liu said primary care doctors are overwhelmed by the amount of mental health care they must provide. Newswise reports "the goal is to help primary care providers get more comfortable as they prescribe medications and refer patients to psychiatrists and therapists." The adolescent version of the program was released last fall and is being used by doctors worldwide. The adult and geriatric version will be released this spring.

Primary care doctor Angie Brennan estimates 35 percent of all visits to her practice have been mental health related. She said there are specific rural challenges to treatment, including "reluctance to see a counselor and a lack of mental health insurance coverage – combined with an intensified fear that someone in the community will find out a patient has mental health issues." (Read more)

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Need for painkillers and social support, shortage of treatment programs, feeds prescription drug abuse in Appalachian Ky.

By Ivy Brashear
Kentucky Health News

Taking opioids is still the best way to treat patients with pain, but the drugs are addictive because they do more than just alleviate physical suffering — they cause patients to feel good too. That's causing big problems in Kentucky, the state with the highest rate of opioid use and overdose.

In Perry County, for example, prescription medicines are the drugs of choice, second only to marijuana, and users may get more of them from relatives than from doctors. And their drug use appears to be part of a social support system.

Those were the findings of three separate studies presented at the second annual Appalachian Health Summit in Lexington last week.

Prescription-drug abuse is "an epidemic" that "seems to have started in rural Appalachia," Jennifer Havens, an associate professor in the University of Kentucky Department of Behavioral Science, said in presenting a study showing how disease spreads through the region.

Havens’ study of Hazard and Perry County found that prescription drug abuse in the county is second to marijuana use, and that painkiller abuse among high school seniors is at the same rate as in adults.

Though it’s not clear why prescription drug abuse is so rampant in the region, Havens speculated that lack of availability of other “hard” drugs, like heroin and cocaine, has led Appalachian drug users to turn to prescription medicine to get high. There are few drug-treatment options for users in the region, and many hospitals aren’t “financially viable” to care for drug abusers, she said.

An earlier study in which Havens was involved revealed that rural adults use more “alternate” methods to take drugs, including snorting and injecting. The study compared drug users in Perry County to those in Louisville and found that more than 40 percent of adults in the Hazard area were injecting prescription drugs to get high, and youth there were 25 percent more likely than those in Louisville to abuse such drugs.

The study found high rates of sharing drug-taking instruments, which increases risk for diseases such as hepatitis and HIV, Havens said. Almost 90 percent of participants said they shared snorting straws, and almost 1 in 3 said they shared syringes. No cases of HIV were found among the participants, but almost 43.7 percent of the 500 interviewed had hepatitis-C, and 11.5 percent had herpes-2.

Eighty percent were lifetime users, and about half first abused Oxycontin through injection. Havens said 28 percent of users had overdosed, and 58 percent had witnessed an overdose.

The study also found that a person’s likelihood of continuing drug use correlated with higher levels of social support, which Havens said contradicts long-held assumptions that drug users continue to abuse prescription pills because of low social support.

“Most people in the study depended on people also using drugs for social support,” Havens said. “As you can imagine, that’s not a good idea.”

No good alternative to prescribing painkillers

Despite widespread opioid abuse in Appalachia, such drugs are “still the best pain therapy,” UK physiology professor Karin Westlund High reported.

The purpose of her study was to determine what effect a high-fat and alcohol diet would have on “visceral pain” in the pancreas, and then what effect opioid gene therapy would have on the organ.

There are clusters of Appalachian counties at high risk for pancreatitis, which can lead to pancreatic cancer. Severe abdominal pain is associated with both, and morphine is typically used to treat it. However, High said, patients usually develop a tolerance to the drug over time.

She and other researchers used rats to test an opioid gene therapy involving herpes simplex-1, which 90 percent of Americans already have, to see if it would reduce pancreatitis pain without building tolerance in the rats. After 10 weeks of treatment, there was no tolerance present and the therapy seemed to be reversing damaged sections of the pancreas caused by the disease.

While opioids are effective in alleviating pain, "There are lots of different kinds of pain, but most opioids act as if they treat the same pain,” said Michelle Lofwall, a UK psychiatry and behavioral science assistant professor. Lofwall set out to discover how pain affects prescription drug abuse, since that is the main reason such drugs are prescribed or first used.

Her study participants, who were all drug users, placed one arm in a cooler of ice to elicit pain, and then were asked about pain levels. The test was repeated after a dose of painkiller.  Researchers were attempting to give the drug to treat patients’ pain only, and not to have the patient feel a high when the drug was in their system, but that failed.

“Unfortunately, in my patients I wanted to say, ‘Yes, let’s treat your pain and you won’t feel any good effects’,” Lofwall said. “I wasn’t able to say that to them.” She said they are now trying to help doctors better prescribe pain medication so that habits aren’t formed.

One of the biggest habit-forming painkillers is Oxycontin, which was introduced in 1996 but wasn’t abused on a large scale until doctors had to start documenting pain in 1999, Lofwall said. Sales of, treatment for, and death from prescription drug abuse have increased since then. She noted that Kentucky has the highest rates of opioid use and overdose.

The makers of Oxycontin have reformulated the drug to make it harder to crush, mix with water and snort, but a new drug has risen to take its place: Opana. Lofwall said researchers have been trying to study Opana use, but can’t get a study supply because it is in such high demand. She said she has seen more of a rise in heroin use by her patients because even heroin is easier to get than Opana.

Though legislators are grappling to curb the proliferation of "pill mills" in the state, Lofwall said "doctor shopping" may not be the problem it's been billed to be. According to the National Household Survey on Drug Use and Health, 56 percent of users get their supply from a relative, of whom 85 percent have a prescription from one doctor. The drug abuser may get the drug from the relative as a gift, by paying for it or by stealing it.

Asked about the Kentucky All Schedule Prescription Electronic Reporting system, which allows doctors to search a database for “doctor shoppers” before prescribing pain pills, Lofwall said KASPER is limited because it only covers Kentucky, but “I think the state’s ready to make it better.”

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

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More foreign-born doctors practice in rural areas, come from poor nations; Kentucky is about average, West Virginia is high

More than 15 percent of physicians in the U.S. received training in lower-income countries, including India, Pakistan and the Phillippines, a new study has found, reports Lori Kersey of The Charleston Gazette. The study was a joint effort by the National Research Council and the Stanley Medical Research Institute, and was published online on PLoS ONE.

Most doctors from low-income countries practice in low-income areas of the U.S., where most U.S.-trained doctors don't usually want to go. West Virginia has the most such doctors, at 29 percent all of physicians in the state. Kentucky has 16 percent, just above the national average of 15.4 percent. Montana, Idaho and Alaska all have less than 2 percent.

The authors of the study said low-income countries that send most of their doctors to the U.S. lost more money training them than they receive in U.S. foreign aid. In 2010, the Phillippines spent $1.7 billion training more than 20,000 doctors who then came to the U.S., but was only given $33 million in U.S. foreign aid. The authors suggest the U.S. should pay those countries back in some way. (Read more)

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Rural newspapers don't write a lot of health stories — but they should, expert says

“If a newspaper can’t stand for better health and better health care, then what in the world can it stand for?” This was the galvanizing statement of a talk today by Al Cross, director of the Institute for Rural Journalism and Community Issues, who keynoted the third annual Kentucky Health Literacy Summit. Cross discussed ways newspapers are — and aren’t — publishing health-related stories on their pages.

A research paper Cross presented with University of Kentucky graduate student Sarah Vos yesterday showed that with a few exceptions, rural newspapers in the state are not publishing many articles about health care and health. The vast majority of articles — 71 percent — run on the inside of the paper rather than on the front page. In large part, stories are institutionally oriented, Cross said, often pertaining to promoting the local hospital or reporting on problems with it.

Interviews with rural publishers and editors in Kentucky and Mississippi showed “while many of them believe health coverage is important, they are reluctant to be seen as crusading in the news columns for a cause, even if it is one that usually has no countervailing interest,” Cross said. He said Kentucky editors are specifically reluctant to point out health disparities comparing their community to neighbors, the state or nation, because they want to build up the community “rather than going out of their way to point out local problems that have no easy solutions.”

Another issue is that most of Kentucky’s 150 newspapers serve very small markets, which “mean less revenue, small staffs and low pay, so most of these newspapers lack the resources to do what we journalists call enterprise reporting,” Cross said. And with all but two Kentucky dailies owned by corporate chains, that can mean “less news space, fewer staff members, more focus on number of stories rather than quality, less focus on community service, more on bottom line,” he said.

However, rural newspapers continue to have considerable influence over their readership, with 60 percent of adults saying their local paper is their primary source of news. Their content is almost entirely local. Thus, Cross said, there are opportunities — and ones that don’t require a lot of legwork. A story about someone's life being saved because she got a cancer screening can make a big impact, he said, and sometimes an article written by an outside source, such as a local extension agent, “doesn’t need to be put on page 12.” Cross said. Newspapers can use social media, such as Facebook, to promote their stories and find local people willing to talk about a health issue.

Cross also recommended Kentucky Health News as a service editors can rely on for stories that can be used verbatim or be easily localized. Cross noted newspapers are using the service, and “We think we are moving the needle.”

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Rural newspapers have power to influence people's health, but few health articles are being published in Kentucky, study finds

By Tara Kaprowy

Kentucky Health News

Though studies suggest that newspapers can influence people's decisions about their health and can even lead to public-policy changes, for the most part Kentucky's rural newspaper editors are publishing very few health-related stories, a report compiled at the University of Kentucky concluded.

The six-month study found more than 1,200 articles  primarily about health were published in 131 rural Kentucky newspapers, including opinion pieces, reprints, press releases, briefs and letters to the editor. That averaged to nine stories per newspaper in six months, though daily papers tended to run far more articles than non-dailies (52 percent of dailies ran health articles 1 to 2 times per week while 68 percent of non-dailies ran health articles less than once a month).

Speaking at the third-annual Kentucky Health Literacy Summit, study co-author Al Cross said he wasn't surprised by the findings, sensing "there wasn't a great deal of coverage out there to help people live healthier lives." But Cross said his goal as director of UK's Institute for Rural Journalism and Community Issues "is to help rural newspapers help define the public agenda."

"In Kentucky," he said, "that needs to be about health."

The topic of health-care funding and policy accounted for 35 percent of the articles published, though co-author Sarah Vos said that number is likely skewed because the time period analyzed included a legislative session during which there was extensive discussion about Medicaid.

Stories on drugs and alcohol accounted for 12 percent of the total, followed by tobacco/smoking (9.5 percent) and exercise, food, diet or obesity (8.6 percent). Vos also found stories that did run were often incomplete, with 40 percent failing to contextualize the problem for the reader. Only 20 percent mentioned health disparities, the differences in health between geographic areas and demographic sectors.

While there is a dearth of health reporting in rural newspapers — all newspapers but those that serve the Lexington, Louisville and Cincinnati areas were included in the study — they could have considerable pull in the health decisions people make. Vos cited one study showing media coverage can influence individual health decisions and preventive behaviors, and one that showed coverage of health issues can lead to both changes in public policy and public perception.

Rural newspapers are well read by their readership, with the average reader spending about 39 minutes reading their local paper. Sixty percent of adults say their rural paper is their main source of news, Vos said. "Rural newspapers have a special relationship with readers," she said. "It's intimate. One researcher even called them an extended member of the family."

For a copy of the paper, click here.

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Affordable Care Act helping families, seniors in rural areas, agriculture secretary says on its second anniversary

The Patient Protection and Affordable Care Act is already making an impact, including for people who live in rural America. That was the message from Agriculture Secretary Tom Vilsack today on the second anniversary of the enactment of the federal health-care reform law.

In a teleconference, Vilsack noted several pieces of the law that are benefitting people, including the 2.5 million young adults who have insurance coverage because parents can keep them on their plan up to age 26. "That's providing a degree of comfort to moms and dads," he said.

The law has also helped 3.6 million seniors on Medicare, who saved $2.1 billion on their prescription drugs in 2011 because the law allowed them to get a 50 percent discount on brand-name drugs. Vilsack said seniors saved an average of $600 last year and were also "able to get a number of services, including preventive services like mammograms, for free."

Under the law, insurance companies are now required to spend 80 percent of their premium dollars on "actual health care, not overhead," Vilsack said, and they are not allowed to increase their premiums by more than 10 percent without an explanation. Children who were previously denied coverage because of pre-existing conditions can no longer denied, as per the law's mandate, and "in a couple of years that will extend to all people," Vilsack said. And thousands of new primary-care doctors and nurses are being encouraged to practice in rural areas and will receive higher payments.

Vilsack said his Department of Agriculture is working to improve the rural health-care landscape, through a joint effort with the USDA Rural Development division and the Department for Health and Human Services. In the past three years, Vilsack said 730 counties have received grants so they can "embrace telemedicine." Nearly 600 health-care facilities in rural communities have received money to fund equipment like CT scans, MRIs, ultrasound and lab equipment, Vilsack said. And rural citizens can now get care from a hospital outside their health plan's network when there is no time to get to a hospital that is farther away.

"No one should have to go without health care because of where they live, and for too long, rural Americans have been getting the short end of the health-care stick," he said. "The Affordable Care Act is helping millions of young people access health care, strengthening Medicare, and training thousands of new doctors to serve rural areas to give middle-class families the health security they deserve." (Read more)

Growing up on farm helps immune system, study of pigs shows

For the first time, there is conclusive evidence that growing up on a farm is good for the immune system. Researchers from the University of Bristol's veterinary sciences school have published a study showing that "spending early life in a complex farm environment" increases the number of T-cells one has, reports Sarah Muirhead of Feedstuffs. T-cells have been identified as universal regulators of immune systems, with low numbers increasing risk of developing allergies, autoimmune and inflammatory diseases. Researcher Marie Lewis said it wasn't previously known whether farm life increased immunity to allergies, or if people more prone to allergies weren't living on farms.

Piglets were used in the study since they share many aspects of human physiology, metabolism, genetics and immunity. Some of the piglets were nursed by their mother on the farm, while the others were kept in an isolator unit under hygenic conditions and fed formula milk to reflect the "extremes of environment" in which many humans are raised. Farm-raised piglets had increased levels of T-cells compared to those raised in the isolator. Lewis said it's not clear yet exactly what caused the increase in T-cells in farm-reared piglets, but said previous work shows that intestinal bacteria "plays a pivotal role." (Read more)

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First showing of 'Remaking Rural Health' is tonight on KET; focuses on people who are making a difference

The spotlight often shines on rural Kentuckians' alarming health problems, but far less attention goes to the people in those communities who are making a difference. "Remaking Rural Health: A KET Special Report" focuses on the advocates who are making inroads in improving conditions in these areas. The first airing of the report is at 9 p.m. Eastern Time tonight.

The report focuses on the expanded use of nurse practitioners, specifically those at Alliance Coal LLC, where a team of practitioners, overseen by Dr. Raymond Wells, run on-site clinics at seven mine sites in the state. It also looks at people like Dr. Phillip Bale of Glasgow who are focused on prevention. Bale runs one of the only "prevention clinics" in the state, spending nearly 30 minutes with each of his patients to identify risks for conditions like heart disease.

With boots on the ground, the goal of the University of Kentucky Rural Cancer Prevention project is to promote prevention by increasing testing and screening for four major cancers, educating through the use of Facebook and text messaging, and having advocates go to places like Walmart to reach out to people.

Awareness is another focus of these advocates. In Montgomery County, the Hispanic population prompted the health department to start the Promotora Program, in which leaders of the Hispanic community are trained in health issues in order to share their knowledge with members of the community. And the Hazard-Perry County Community Foundation aims to build health values in the community to try to change health outcomes.

The report will air again at 10 p.m. EST Monday, Feb. 13, and will be available online. For more information, click here.

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In front-page editorial, rural weekly in Adair County demands that board members of county-owned hospital resign

In our experience, most weekly newspapers don't have editorial pages, much less editorials, so when one puts an editorial on the front page and also runs an editorial about the decision, and the work is well-written and well-argued, it's worth noting.

The Adair County Community Voice in Columbia, Ky., noted county government's bailout of the "collapsing" county-owned hospital; elected officials' request that they have "a say in any final decision to sell the hospital" and that "the hospital administration will try just as hard to keep the hospital independent as they will to sell it;" and some appointed board members' dislike of the requests.

"It seems like little to ask of someone who is $13 million in debt and asking you for $1.7 million," the editorial said, noting that one member said the board had been "a rubber stamp" for agents who secured the bonded debt. That admission "saves us the trouble of trying to prove that board members acted irresponsibly in overseeing the hospital’s business," the editorial said. "Now the question has to be, 'Why are they still on the board?'" It said the board not only "ran the hospital into the ground" but is "in control of a document that will show if any criminal activity took place," a forensic audit that gives board members "a personal stake in any damaging evidence that may come out."

In her explanatory editorial, Editor-Publisher Sharon Burton said she put the editorial out front because "We believe this is a critical time for our community, and we believe bad decisions will continue if the board is left as it is. We believe it’s our job to bring the issue to the forefront, and there is no better place to do that than on the front page of the Community Voice." The explanatory editorial also included useful background and perspective, including: "At small newspapers we don’t have the luxury of separating the people who cover the news from the people who write opinion pieces. Instead, we work hard to provide fair and unbiased coverage of local news. Then, we look at how that news impacts the people in our community and take a stand as needed on our editorial page."

Burton told us in an email that the editorial generated responses by phone, emails, Facebook messages "and of course being stopped at church and the grocery store," all of them positive except a letter from the daughter of a board member, which is running this week. The Community Voice doesn't put editorials or most news online, but PDFs of the pages with the editorials are available on the Institute for Rural Journalism and Community Issues website. The front page, with color, is 3.5 MB; the inside page is 682 KB.

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Federal cuts, financial instability and competition leave many rural hospitals fearing the future

Many rural hospitals could be forced to close because of cuts to the Critical Access Program and the fact that, according to the National Rural Health Association, , 41 percent of critical-care hospitals are losing money, reports Jenny Gold of Kaiser Health News. This would be devastating to many rural communities, with a great impact felt by low-income and elderly residents. "A small hospital is often one of the biggest employers in a rural town, and closures 'can have an outsized economic impact,'" Eric Zimmerman, a health care lawyer and Washington lobbyist, told Gold.

More than 1,300 U.S. hospitals and nearly one in four acute-care facilities are designated as "critical access," giving them slightly higher Medicare and Medicaid reimbursements in return for limits on care they can provide. Many such hospitals like Hood Memorial, about an hour outside New Orleans, are dealing with uninsured patients, inability to collect payments from patients, and fewer funds from federal and state agencies, Gold reports. Many of these hospitals "tend to provide lower quality care" and are "less financially efficient than other facilities, according to a 2010 study published in the Journal of Health Politics, Policy and Law. Hood, for example, had $700,000 in losses last year despite the higher reimbursements. "It's a lot of variables, and all of them right now are working against us," CEO Hoppie Jones told Gold.

To prevent closures of rural hospitals and ensure "Americans in in isolated areas would still have access to health care," the federal government started the critical access program in 1997. To qualify, hospitals had to have 25 or fewer beds and be at least 35 miles away from another facility. However, states could waive the distance requirement, and many did, leaving hospitals like Hood with at least four other competing hospitals "within a 26 mile radius," Gold reports.

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Farmers work long past regular retirement age, and many doctors lack the knowledge to help keep them healthy

"Farmers' stark commitment to work is borderline obsessive, and researchers are beginning to develop new guidelines to better understand farmers, whose strong cultural and emotional ties to the farm drive their work ethic," reports Karin Pekarchik of the University of Kentucky College of Agriculture about a study by the UK College of Nursing's Deborah Reed. Findings show that 40 percent of 1,423 Kentucky and South Carolina farmers aged 50 and over defined health as the "ability to work," causing them to work well after retirement age. Reed told Pekarchik she hopes these results will help medical personnel better understand farming culture so they can better relate to farmers.

"The average Kentucky farmer is 57 – 13 years older than the average worker. Kentucky's farming population mirrors that of the entire United States, making this a nationwide topic," Pekarchik writes. Reed told her most farmers have two jobs and don't list farming as their primary occupation, keeping doctors from screening for things like skin cancer and cataracts, common ailments associated with working outdoors.

Another alarming statistic is that farmers have the highest suicide rates of any occupation, most likely because they're "exposed to unrelenting and multifaceted stress and pressure," Pekarchik writes. The resulting stress from hard physical labor, long work days throughout the year, enduring vagaries of nature and livestock, adverse weather conditions, market fluctuations, government policy changes and family pressure can lead to suicide.

Reed told Pekarchik farmers, even from a young age, should be aware of the physical and mental problems that could ail them later in life. Reed suggests farmers use sunscreen, wear wide-brimmed hats, use hearing protection and wear sturdy shoes and use a walking stick to eliminate falls. (Read more)

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Center for Excellence in Rural Health marks 20th anniversary by adding new program in medical lab science

The University of Kentucky’s Center for Excellence in Rural Health celebrated its 20th anniversary this week and announced the addition of a new baccalaureate degree in medical laboratory science, which will start next fall at the facility in Hazard.

At a ceremony honoring current and former faculty, staff and students of the center, speakers include UK President Eli Capilouto, 5th District U.S. Rep. Harold "Hal" Rogers and Dr. Wayne Myers, the center’s first director and a former director of the federal Office of Rural Health Policy.

Capilouto, a dentist by trade, said “With approximately 80 percent of the center’s graduates working in Appalachia or other rural communities, it’s a testimony to the fact that this idea worked.” More than 550 people are graduates of the center's academic programs. The center also includes Kentucky Homeplace, a nationally recognized community health worker initiative; the Kentucky Office of Rural Health; and the East Kentucky Family Medicine Residency Program, a UK news release said.

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Primary care and management of chronic diseases could soon be coming to your local Walmart store

Just weeks after announcing part-time employees would no longer receive health insurance benefits, Walmart said Monday it is planning to offer extended medical services in its stores, report NPR's Julie Appleby and Sarah Varney. Since many of its stores are in rural areas, this move could extend medical coverage to people who often can't afford transportation to a doctor. The retailer "sent out a request for partners to help it 'dramatically lower the cost of health care by becoming the largest provider of primary health care services in the nation.'"

In a 14-page request, Walmart asks health-care providers to define their expertise in a variety of medical areas, including managing patients with chronic health problems like asthma, HIV, arthritis, depression and sleep apnea. The retailer is also trying to find health partners who can monitor patients with diabetes and high blood pressure. Appleby and Varney say "The move would capitalize on growing demand for primary care in 2014, when the federal health law fully kicks in and millions more Americans are expected to have government or private health insurance." This effort could also capitalize on "collaborations between doctors and hospitals to streamline care and lower costs," they report.

Though expansion of medical services in Walmarts "could help lower costs for some patients and increase access to primary care services," it has its fair share of nay-sayers. Glen Stream, president of the American Academy of Family Physicians, tells Abbleby and Varney that Walmart's "proposal takes health care in the wrong direction by further fragmenting care. Ann O'Malley, physician and senior researcher at the Washington think tank Center for Studying Health System Change, said she's not sure Walmart's approach will work. She said she "would be surprised if this were a model that could truly attack cost problems." Colin McGranahan, retail analyst for Sanford C. Bernstein & Co., said this could simply be a move to boost foot traffic and sales in Walmarts: "If you get someone in the door, you can also sell them milk and a shotgun." (Read more)

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Thursday, Nov. 17, will be first National Rural Health Day

Nov. 17, 2011 will be the first annual National Rural Health Day sponsored by the National Organization of State Offices of Rural Health. The goals of the event are to highlight rural communities as wonderful places to live and work, increase awareness of rural health-related issues and promote the roles of state rural-health offices in addressing those issues.

On Nov. 17, the organization will host a series of free webinars in conjunction with the observance. To learn more about the webinars, click here. The group also has a series of free tools newspapers can use to promote the event. (Read more) The Center for Rural Health is hosting a photo contest to promote the event. To find your state's rural health office, click here.

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Rural children face more health risks; most parents say their kids are healthy

Children in rural areas face more health challenges than those in urban parts of the country, and are more likely to be poor, more vulnerable to death from injuries, and more likely to use tobacco. Rural families also have more difficulty in gaining access to health care. But the majority of parents, regardless of whether they live in urban or rural communities, say their kids are healthy.

These findings are from a report entitled "The Health and Well-Being of Children in Rural Areas: A Portrait of the Nation 2007," compiled by the U.S. Department of Health and Human Services' Health Resources and Services Administration. The report's results are based on the National Survey of Children's Health, conducted in 2007.

The survey classified children as living in an urban area, a large or well-populated rural area or a small or isolated rural area. Large rural areas include large towns with populations of 10,000 to 49,999. Small rural areas include small towns with populations of 2,500 to 9,999. Survey results were not broken down by state.

The report found children's overall health status does not vary substantially according to location. Four-fifths of parents said their children are in excellent or very good health, regardless of where they live.

But the analysis found rural children, as a whole, face more health risks than their urban counterparts. Only 67.6 percent of children in large rural areas and 69.8 percent in small rural areas are breast-fed, compared to 77 percent of urban children. (About 59 percent of new mothers breast-feed in Kentucky, compared to 75 percent nationwide.)

Rural children are also more likely to be overweight or obese — 34.6 percent of children in large rural areas and 35.2 percent in small rural areas compared to 30.9 percent of urban children. Rural children are also more likely to live with someone who smokes — one in three children in large rural areas and 35 percent in small rural areas do. Only one in five urban children do.

Though about 90 percent of children surveyed had health insurance, those in rural areas were more likely to have public coverage like Medicaid or CHIP. Urban children were more likely to have private insurance. Access to health care also remains a factor. Of the 2,052 non-metropolitan counties identified in 2010, 704 were designated as health professional shortage areas. Of those, 467 had shortages for dental care and 521 lacked adequate mental health services. To find if a Kentucky county is in a health professional shortage area, click here.

There are some advantages for rural children, however. They tend to be better protected and more connected to their families and communities. More than half of children in small rural areas shared a meal with their families every day in the past week. Children in small rural areas are also more likely to get physical activity every day (34.7 percent), though they are less likely to have access to community centers, parks or playgrounds. However, rural children are more likely to spend more than an hour each weekday watching television or videos — 60.9 percent of children in large rural areas did so, compared to 53 percent in small rural areas and 53.9 percent of urban children.

The data for the National Survey of Children's Health was generated using a random telephone survey, in which 2.8 million telephone numbers were randomly generated. After non-working and non-residential numbers were eliminated, the remaining numbers were called and surveyors spoke to respondents to see if children less than 18 years of age lived in the household. From each of those households, one child was randomly selected to be the focus of the interview and parents responded to the survey questions. Surveys were conducted in English, Spanish, Mandarin, Cantonese, Vietnamese and Korean.

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Americans having to travel farther to get trauma treatment as hospitals close

Millions of Americans are farther away from trauma care than they were 20 years ago, with some having to travel more than 30 minutes to get treatment. Experts say getting help within the first hour is crucial.

A study published in the journal Health Affairs found the distance to a trauma center "increased for 69 million people between 2001 and 2007," reports the Daily Yonder, the national online rural journal. The average amount of travel time was 10 minutes. But for 16 million people, the amount of time it took to travel to a trauma center increased by 30 minutes or more.

"The greatest impact from diminished access has been on people in rural communities," as well areas with a high percentage of African-American residents, low-income people and those without health insurance, The Associated Press reported.

Though U.S. Census numbers show cities growing in population while rural areas decline, Kentucky is still considered a largely rural state (see right), ranking 23rd in the country for population density.

The reason for the increased travel times is due to facilities closing. In 1990, there were 1,125 trauma centers in the country. By 2005, nearly 340 of them had closed, in most cases because of financial hardship; they were treating too high a percentage of people who do not have insurance, Daily Yonder reports.

President Obama's recent call to cut Medicare premiums to critical access hospitals, as well as close CAHs that are within 10 miles of each other, would further burden rural areas, said a panel of experts in Lexington Wednesday.

Medical experts say a trauma patient has the highest change at survival if treated within the first hour. "We're not saying that we should build a trauma center on every street corner," said Dr. Renee Hsia, lead researcher on the study. "But we do have evidence that access for certain populations is already pretty bad, and it's getting worse." (Read more)

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Natl. Rural Health Assn. president, at UK, says rural health cuts won't save money or help communities but will eliminate jobs

Speaking about President Obama's proposed cuts to rural health care Wednesday, Susan Starling was frank about her feelings: "As a CEO of a critical access hospital, I'm very nervous. What do I need to do as a hospital administrator?" she asked Alan Morgan, chief executive officer of the National Rural Health Association.

"If at all possible, invite your legislator into your facility," Morgan replied. "When they see what you're doing for your community, that's what will turn the tide on this."

The conversation was part of the Healthcare Spotlight Series at University of Kentucky Albert B. Chandler Hospital in Lexington and put on by The Health Enterprises Network in partnership with Hall Render. Morgan was the keynote speaker and Starling, CEO of Marcum & Wallace Memorial Hospital in Irvine, moderated the subsequent discussion. They spoke at length about President's Obama's recent call to reduce reimbursement payments for critical-access hospitals as well as eliminate the CAH designation for those within 10 miles of another hospital.

Morgan, whose association has 21,000 members, said there has been discussion about making cuts to rural health facilities for the past year, starting when the Congressional Budget Office released its proposals for potential savings in March and proposed eliminating CAHs. "Once you put something like that on the table, it stays on the table," Morgan said. The Medicare Payment Advisory Commission followed suit, suggesting the same cuts Obama ultimately called for in September.

Morgan said the proposal runs counter to efforts to create jobs, saying closing CAHs and reducing reimbursement — which he said would force many to close — will eliminate far more jobs than it creates. "We have a hard time communicating to policymakers that if the health care system is not the largest employer in a rural community, it's second only to the school system," he said. "Health care is about the economy."

While cuts may be on the table and the health-reform law is not perfect, Morgan said, it does allocate a "tremendous amount of federal resources" to rural health, most in the form of grants and special programs. But Morgan said much remains to be decided about the law. "If someone tells you it's great, they don't know if it's great. If someone tells you it's bad, they don't know that either," he said. "They just don't know yet. Until the regulations come out on most of this we just don't know."

That being said, Morgan does not feel the act will "fix rural America" since "there is no silver bullet." But he pointed to good things about rural health, such as studies showing that rural facilities outperform their urban counterparts in primary care, safety and preventive services. "As a nation, as rural advocates, we need to be proud of what we do when it comes to quality, when it comes to innovation," he said. "What makes rural great is a strong sense of community, which allows you the ability to network . . . to try innovative approaches."

But doing that takes money, Starling and Morgan agreed. "Just by cutting, we're not changing the system," Starling said. "If we close hospitals in rural America, we're not saving money. We're shifting it to urban. It's actually spending more."

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Frontier Nursing Service sells Mary Breckinridge Hospital to Appalachian Regional Healthcare

Following the nationwide trend of independent hospitals joining larger organizations in order to stay viable, and ending an era, Hyden's Mary Breckinridge Hospital has been acquired by Appalachian Regional Healthcare.

The hospital was sold by the Frontier Nursing Service, which was founded in 1925 by Mary Breckinridge, whos eefforts greatly reduced infant mortality in the area. The hospital employs 150 people and will now be called Mary Breckinridge ARH Hospital, The Associated Press reports.

ARH President and CEO Jerry Haynes said the health system hopes to enhance health-care services in Leslie County. It is the 10th hospital in the Central Appalachian network, which began with takeover of United Mine Workers hospitals about 40 years ago. (Read more)

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Seven UK docs-to-be off to Morehead to train in rural medicine

Learning how to practice in rural areas is the goal of seven University of Kentucky medical students, who are off to Rural Physician Leadership Program in Morehead. (From left: Shea Poynter, Lesley Jackson, Katherine Johnson, Nathan Hudson, Katrina Winkler, Crystal Norgren and Miranda Smith)

The program "trains physicians to become practitioners and leaders for rural areas," Julie Meador writes for UKNow, the university's news service. "It was created in response to the growing health care needs evident in rural areas of Kentucky and the rest of the nation."

The training is primarily done at St. Claire Regional Medical Center and with physicians with the Northeast Area Health Education Center, who are serving as preceptors. The students will also take courses at Morehead State University's Department of Business and Public Affairs on the medical use of information technology, financial issues and debt management and community engagement for health policy.

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Area Health Education Centers work behind scenes to make a difference, help bring health providers to rural areas

By Tara Kaprowy

Kentucky Health News

When student Holly de la Peña learned she'd been assigned to a physician's assistant rotation in rural southeastern Kentucky, she was a little nervous. Having grown up in Paris, Ky., near Lexington, and having never ventured much farther than the 30-minute drive to the University of Kentucky, the prospect of going to live for six weeks in a town she'd never visited with a family she'd never even met was intimidating. "I was very anxious to travel alone and stay in a strange environment and not have any friends in the area," she recalled. "It was a little scary."

But after arriving in London, Ky., de la Peña realized things were going to be just fine, thanks in no small part to the local Area Health Education Center that helped her. "They did everything for me," she said. "They gave me the connection of where to stay, they gave me information about the community. They even gave me a list of restaurants, activities that were offered and where certain churches were located." In fact, de la Peña found the experience so rewarding and she became so connected to the town, she and her husband decided to move to London shortly after her graduation. She's been practicing as a physician assistant there for the past 10 years.

Stories like de la Peña's are exactly what staff at Area Health Education Centers, which serve every county in the state, are hoping to hear. "It's gratifying to know that the work our staff pays off for our region," said Dwain Harris, director of Southern Kentucky AHEC. (Photo: Dr. Brian Ellis of Danville works with UK medical student Megan Song)

Though they can go unnoticed, AHECs have been working behind the scenes for decades. The program started as a federal initiative in 1971 and was designed to get more doctors working in rural areas. "Particularly rural communities had a hard time getting enough doctors," said Dr. Jim Norton, the UK medical school's associate dean for educational engagement. "They felt if medical students spent part of their time training in rural areas they might then practice in rural, underserved communities."

In 1972, Kentucky applied to receive money from the federal initiative. When it was denied, the state decided to set up its own system, calling it AHES — the Area Health Education System. That system was designed to serve and attract all types of health-care providers, not just medical students. "There was funding provided to support students when they went away from the mother ship to an underserved community," Norton said. "And there were staff scattered around the state that were the local contacts to help them find housing."

Around 1980, the University of Louisville and University of Kentucky decided to try again to receive federal funding. It was granted, and the state has been receiving about $700,000 every year since. In turn, the state kicks in about $2 million each year. AHES changed its name to AHEC when centers were set up across the state. Today, there are eight such centers, four in Western Kentucky administered by U of L and four in Eastern Kentucky administered by UK.

The main goal remains the same: link students in all types of health professions to rural and underserved training sites, such as clinics, hospitals and physician offices. From 2008 to 2010, student physicians, nurses, pharmacists, dentists and allied health professionals such as physician assistants received training at more than 10,000 AHEC-supported rotations. In 2009-2010, 1,727 students did AHEC rotations representing more than 8,700 student work weeks.

YOUTH PIPELINES

Over the years, the program has expanded. Now the work to attract health professionals to rural areas starts well before students are getting ready to graduate from college. Called health career pipeline programs, AHEC staffers work with middle- and high-school students to encourage them to pursue health careers. "We stress the importance of taking math and science courses, about how it's important not to take a year off after high school, and we allow them to shadow health care providers," said Carlos Marin, AHEC program administrator at UK. (Photo: Rockcastle Regional Hospital nurse Bill Wells demonstrates nursing skills on a mannequin during Southern Kentucky AHEC's 2011 summer health-careers camp.)

In the last school year, more than 23,000 kindergarten to 12th-grade students in Kentucky were exposed to some type of health career activity, including classroom presentations, camps, clubs and workshops.

De la Peña's 15-year-old son Evan is now part of the pipeline. This summer he attended an AHEC-sponsored science and health camp. He learned fundamental suturing techniques and how to start an IV, became CPR certified, and attended lectures by several health-care professionals. "Even if your child doesn't want to be a doctor, they're learning about all of these different professions that they wouldn't have the opportunity to learn about, unless someone in their family had that type of job," de la Peña said. "Plus, it lets them recognize the need in a small community."

SERVING THEIR COMMUNITIES

The AHECs' official motto is to "connect students to health careers, health professionals to communities and communities to better health," but each center works independently to meet local needs. Part of the work at the North Central AHEC, for example, is reaching out to its Hispanic community. At the Purchase AHEC, there is a vigorous oral health initiative. In Mount Vernon, maternal education is a major focus, with the Southern Kentucky AHEC hosting educational baby showers to help combat the area's high rate of premature births.

Northwest AHEC, which covers Louisville and seven nearby counties, helps people who lost their jobs get trained in health care professions and back to work. "We're working with the workforce development boards real closely," said Center Director Brenda Fitzpatrick. "We're helping displaced workers look at other careers because there is a slew of health care careers that will support this system. The health care industry is the fastest growing job industry right now. There's a whole new gamut out there for us."

RESULTS?

But do AHEC efforts reach the original goal, to get more health professionals working in underserved areas? Officials admit it's a difficult question to answer, partly because many students are now required to do rural rotations. "If you look at the history of it, from an anecdotal view, yes, it does work," Marin said. "The question is: Can we say X number of students have gone through AHECs and so have gone to rural communities? No. It's difficult because all of our students go through AHEC rotations."

Even asking a doctor why he or she decided to practice where he or she does can have a complicated answer. "The answer is going to be a whole lot of things," Norton said. "He might say, well, I grew up here. Or I did a rotation here. Or my family was here. To identify what is the cause is probably futile because there is a combination of factors."

De la Peña agreed. She and her husband already knew they wanted to return to small-town living when they had children, for example. But AHEC cemented the deal, and kept her in Kentucky. "With AHEC going out of their way to make your stay as accommodating as possible, to make you feel comfortable and giving you an opportunity to mesh with a community, that does establish some roots," she said. "You meet people, they befriend you, you keep in touch, you want to come back. And that can lead to future employment."

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