Addressing Rural Health Disparities in Illinois

PUBLIC HEALTH PRACTICE IN Special Issue Winter 2006 Volume 6, Number 2 Addressing Rural Health Disparities in Illinois Editor’s Preface Identifying Rural Community Health and Social Service Training Needs Mid-America Public Health Training Center Health Status Disparities among Adult Rural Illinois Minorities Illinois Department of Public Health What do Consumers Say About Locally-Provided Health Care in Rural Illinois? Results from a Focus Group Study of Community Perceptions Community Health Mapping: Participation, Collaboration and Positive Outcomes Effective Chronic Disease Translation: A Regional Diabetes Coalition Addressing Rural Health Disparities in Illinois: Oral Health 1 3 9 27 41 49 59 Public Health Practice in Illinois (formerly Illinois Morbidity and Mortality Review) is a joint publication of the Mid-America Public Health Training Center and the Illinois Department of Public Health _____________________________ Founding Editors: Louis Rowitz, PhD Mid-America Regional Public Health Leadership Institute Merwyn Nelson, PhD Illinois Department of Public Health Guest Editor: Michael Glasser, PhD University of Illinois - Rockford Managing Editor: Fasika Alem, MPH Contributors: William W. Baldyga L. Kathleen Brown Paul K. Burkholder Mary Jane Clark Tess D. Ford Julie A. Jensen Linda M. Kaste Anne L. Koerber Lewis N. Lampiris Susan R. Levy Martin MacDowell Saugar Maripuri Heather McIlvaine-Newsad Paul McNamara Karen E. Peters Kim Sanders Joella D. Warner Kerry Whipple Mid-America Public Health Training Center UIC School of Public Health, M/C 923 1603 W. Taylor Street Chicago, IL 60612 http://maphtc.uic.edu/Public/ Journal information and subscriptions may be accessed at http://maphtc.uic.edu/Public/ Information for subscribers and contributors can also be found on the back page of the journal or at http://www.uic.edu/sph/chs/php ________________________ EDITOR’S PREFACE This issue of Public Health Practice in Illinois focuses on reducing health disparities in rural Illinois communities. Health disparities populations are defined as any group exhibiting significant disparities in overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates as compared to the health status of the general population. Disparities can be particularly acute in rural areas and populations, where 20% of Americans live, but only 9% of the nation’s physicians practice.1 Additionally, heart disease, cancer, and diabetes rates are higher in rural areas, people in rural settings are less likely to use preventive services, exercise regularly, or wear safety belts, and individuals often lack access to treatment because appropriate transportation is too expensive, limited by weather conditions, or people are too sick to use available options.2,3 Nationwide, the government, among various options, has created EXPORT Centers to study and develop programs that address health and health care disparities. These centers were established through the Minority Health and Health Disparities Research and Education Act of 2000 (Public Health Law 106-525) for the express purpose of conducting and supporting research, training, dissemination of information, and other programs with respect to minority health conditions and other populations with health disparities.* The articles in this issue of Public Health Practice in Illinois provide important information about and insight relative to addressing health disparities at multiple levels. Themes that emerge in these papers include the development of community and academic partnerships, where the resources of the latter are brought to bear on the former. But as pointed out in more than one of the papers, communities need to be involved at the start in identifying their own problems in order to focus on local priorities and implement strategies that will be sustainable. Further, the papers demonstrate the significance of partnerships and bringing together multiple stakeholders in both identifying needs of rural communities and populations and developing and implementing interventions. Finally, the importance of evaluation is demonstrated as the majority of the papers offer strategies for collecting data that will enhance the understanding of the results of program implementation. It is also notable that the papers in this issue cover the state of Illinois as a whole, with some providing results of initiatives in southern compared to northern Illinois and others taking the entire state as the focus. Overall, the papers represent the range of work that is going on to help address health disparities in rural Illinois. In this regard, Sanders et al. (“Identifying Rural Community Health and Social Service Training Needs”) provide a well-thought out needs assessment of rural health and social service agencies in order to identify and prioritize workforce training needs for these community agencies. They collect primary data that will be essential for the development of workforce training programs. Maripuri and MacDowell (“Health Status Disparities among Adult Rural Illinois Minorities”) delineate healthcare needs and disparities between minorities and whites, focusing on outcomes related to heart disease, motor vehicle accidents, homicide, lung cancer and malignant neoplasms, diabetes, use of emergency medical services, and hospital discharges. The researchers present a scheme for studying and understanding these disparities, finding significant differences in the outcomes of rural minority populations related to homicides in younger adults -2- and mortality in seniors due to heart disease, lung cancer, and diabetes. McNamara and Brown (“What Do Consumers Say About Locally-Provided Health Care in Rural Illinois? Results from a Focus Group Study of Community Perceptions”) provide interesting insights into what rural community residents want and expect in relation to healthcare access and delivery. As the authors state, study results can be used as input into the strategic planning process of hospitals as well as to help target and focus efforts in quality improvement. At the level of intervention and quality of health care, McIlvaine-Newsad and Clark (“Community Health Mapping: Participation, Collaboration, and Positive Outcomes”) provide details on a program for assisting rural populations in identifying health care priorities and mapping strategies for achieving them. They offer a replicable process, with proven success, that takes into account local or grassroots input - offering the possibility for long-term sustainability. Burkholder and Warner (“Effective Chronic Disease Translation: A Regional Diabetes Coalition”) further describe the process of development of a community coalition, or a “how-to” in coalition development. Much detail is provided in the description of the evolution of the diabetes coalition, as a result of a local needs assessment, to actual products and outcomes from the work of the organization. Finally, Peters et al. (“Addressing Rural Health Disparities in Illinois: Oral Health”) conclude that rural residents experience a disproportionate burden of oral health care in Illinois. Most importantly, the investigators offer strategies and solutions in the policy goals of the Illinois Oral Health Plan. Overall, this issue of Public Health Practice in Illinois offers insights into both the health problems and disparities in rural Illinois as well as directions in their resolution. Michael Glasser, Ph.D. Associate Dean for Rural Health Professions Research Associate Professor of Medical Sociology References 1. 2. 3. US Department of Health and Human Services. (2003) National Healthcare Disparities Report. www.healthypeople.gov Healthy People 2010: An Overview. Wattenberg EE. (2000) Factors affecting health disparities in rural areas. In Health Care Disparities in Western New York. * The National Center for Rural Health Professions at the University of Illinois - Rockford has been designated as an EXPORT Center for Excellence in Rural Health (supported by grant number P20 MD000524 from the National Center on Minority Health and Health Disparities, National Institutes of Health). Identifying Rural Community Health and Social Service Training Needs Kim Sanders, MBA Illinois Delta Coordinator and former Education Coordinator Center for Rural Health and Social Service Development (CRHSSD) Tess D. Ford, RN, PhD Director of the Center for Rural Health and Social Service Development, and Adjunct Faculty, Department of Health Education and Recreation, Southern Illinois University of Carbondale Kerry Whipple, MS, CHES Graduate student in Health Education Southern Illinois University T he Southern Illinois University at Carbondale’s (SIUC) Center for Rural Health and Social Service Development (CRHSSD) is engaged in program evaluation, research, needs assessments, grant and project development, curriculum development and training related to rural health and social services issues. The mission of CRHSSD is to develop healthier rural communities by identifying and addressing health concerns in partnership with those committed to improving health and social services. The purpose of this needs assessment was to identify priority health and social service staff training and continuing education needs for the southern 22 counties of Illinois. The health and social concerns affecting our society today are often overwhelming. Emerging physical and social diseases are a constant source of pressure for healthcare and social service professionals who are trying to stay abreast of new trends and treatment. Continuing education and staff development are critical in today’s healthcare and social services workforce. Unfortunately, little attention has been focused on how fundamental changes in healthcare are influencing the competency requirements and continuing-education needs of the currently employed healthcare and social service workforce (Allegrante, et al, 2001). The goal of continuing education is to provide staff with “those experiences that assist in the development or enhancement of knowledge related to specific responsibilities as part of an individual’s professional occupation...” (NCHEC, 2001). According to Klusch (2002), the credibility of an agency is related to the knowledge of its employees. Speaking specifically of a nursing home, Klusch said “…the knowledge base of a facility’s staff and management is the foundation of that facility’s quality of care…” Many organizations attempt to fulfill the need for continuing education through brief in-services. Unfortunately, the task of educating staff is broader than in-services. In addition, most professions that have a Code of Ethics consider -4- Public Health Practice in Illinois continuing education as part of the individual’s responsibility. Therefore, as rural agencies and organizations attempt to provide continuing education for staff, several barriers reveal themselves. Continuing education must be placed at the forefront of our healthcare and social service workforce if we are to meet the challenges ahead and contribute to national efforts to achieve the goals and objectives of Healthy People 2010 (Allegrante, et al, 2001). For example, availability and accessibility to care is at the top of the list of health needs according to both Healthy People 2010 and Rural Healthy People 2010. Rural communities, especially, find this issue challenging as transportation issues exacerbate the problem of a lack of providers. As rural communities try to address this issue, provider and educator recruitment becomes a significant barrier. Finding educators who are qualified and competent to address emerging health issues presents the same barriers as that of finding providers who are willing to relocate to a rural setting that typically does not have the same pay scale. Therefore, many times rural agencies must attempt to train current staff rather than hire new staff. However, offering effective training or sending someone away to training is usually not financially possible. For example, keeping nursing staff up to date on emerging issues is critical for quality of care. However, nursing staff development is often the first to go when the budget scissors come out, leaving critical tasks in staff development and competency assessment to fall on the shoulders of already burdened managers (Squires & McGinnis, 2001). In addition, when current employees are asked to take on additional tasks or are provided with promotions to supervisory status, they often do not feel confident in their new roles. Therefore, feelings of unhappiness and resentment can lead to loss of the only staff available and when staff members are promoted into a supervision role, they may lack essential training to provide quality supervision. Significance of the Study As rural communities seek to recruit and maintain qualified and competent staff to provide needed goods and services, providing continuing education opportunities on relevant topics is key to keeping staff confident and satisfied. The needs assessment was intended to guide the development of training opportunities for healthcare and social agencies in rural southern Illinois. The results of this needs assessment could also be used to compare with other rural training needs assessment findings. This needs assessment provides a model for developing and conducting similar training needs assessments targeting rural health care and social service providers. Research Design and Methodology Study Sample An initial invitation to participate, which explained the purpose and plans for disseminating results, an instruction sheet for participants, and the four page assessment instrument itself were distributed in early December 2002. Agencies were asked to respond indicating their willingness Rural Health Training Needs -5- to participate by the end of December 2002 and were asked to designate the number of surveys that would be needed to complete the training needs assessment within their agency. An introductory letter was mailed to all non-profit health care and social service agencies (67 agencies) identified in the southern twenty-two counties of Illinois. The Education Coordinator used phone directories, statewide lists, and other agency lists to identify all non-profit health and social service agencies in the following counties: Alexander, Pulaski, Massac, Pope, Hardin, Johnson, Union, Jackson, Williamson, Saline, Gallatin, White, Hamilton, Franklin, Perry, Randolph, Jefferson, Wayne, Wabash, Edwards, Marion, Washington. Of this group, twenty-one agencies representing twelve counties initially elected to participate in the training needs assessment. Completed surveys were received from nineteen agencies (28.4%) representing twelve counties (54.5%). This response resulted in a total of 990 total surveys. Instrumentation In May 2002, instrument development began with guidance from a Regional Training Committee (RTC) consisting of representatives from health and social service agencies throughout the region. Goals and objectives for the assessment instrument were formed along with a comprehensive list of job titles employed within agencies. These job titles were organized into categories of Support, Direct Service, or Supervisors/Administrative Staff. Support staff included job titles such as clerical, fiscal or accounting, maintenance, and transportation. The direct service category included such titles as counselor, nurse, outreach, psychiatrist, advocate, dietician, case manager, youth worker, etc. The supervisor category included titles such as supervisor or coordinator, senior administrator, and human resources. For each category, a list of possible training need areas were developed. While the survey was intended to be comprehensive, options were made available to write in other training needs not identified. Data Collection Procedures Completed surveys were returned both by mail and in person. Respondents identified themselves as representing one of the following agency types: senior services, mental health, public health, health clinics, family services, youth services, home health, rehabilitation, long term care, domestic violence, pregnancy services, social services, and hospitals. In addition to agency categorization, respondents categorized themselves as support staff, direct service staff, or supervisory/administrative staff. Respondents were asked to prioritize the need for training on a variety of topics using the ratings of high, medium, low, or none with scores of 3, 2, 1, and 0, respectively. Space was also provided to list other topics where training might be needed. Respondents could select more than one area as a high priority. Topics were listed separately for each category of staff designation. Respondents were asked to fill out their primary staff category section and, also, a supervisory/administrative section if it applied. -6- Public Health Practice in Illinois Data Analysis The data were entered into SPSS and analyzed by individual agency and type of agency. For each item, a frequency and percent were tabulated. The final summary reflects all agencies and respective respondents reporting within a given staff type category. Findings The results for each individual agency were disseminated only to that agency. Training topics which were prioritized as low to medium need will not be addressed in this publication due to the diversity of topics among various agency categories. Each agency may use their information to address their particular training needs individually. The following topics were prioritized by participants as medium to high need for training and identified by at least half of all the provider categories. The top training priority areas for staff by category are listed below: Training Need Support Staff Training Needs Average Score 2.41 2.54 2.32 2.25 Number of Agency Categories (n) 10 8 8 8 Patient/client service Accountability & Documentation Telephone etiquette Basic computer skills Direct Service Staff Training Needs Training Need Average Score Number of Agency Categories (n) Patient/client service 2.40 12 Developing patient relationships 2.31 10 Engaging difficult clients 2.28 9 Crisis intervention 2.24 7 Conflict resolution 2.30 6 Supervisors/Administrators Training Needs Training Need Average Score Number of Agency Categories (n) Team building 2.40 10 Setting & achieving goals 2.47 9 Personnel issues 2.45 7 Motivating staff 2.25 7 Conflict resolution 2.24 7 Legal & liability issues 2.27 7 Time management 2.20 7 Rural Health Training Needs -7- Discussion In the category of support staff, basic skills training including computer skills and documentation are needed in addition to basic customer service training, such as client service and telephone etiquette. These are fundamental skills which are sometimes taken for granted in the hiring process. Direct service staff identified top training needs that included both basic customer service skills and more specific client/patient needs. Crisis intervention and conflict resolution can be considered on both a patient level and a staff level. The topics of client service, developing patient relationships, and engaging difficult clients seem to relate directly to more proficient client service skills. The training needs identified by supervisory/administrative staff can be grouped into the categories of: (1) staff leadership and management, with the topics of team building, motivating staff, and conflict resolution and (2) a more concrete category of task management, with personnel issues, time management, setting and achieving goals, and legal and liability issues. These two very different categories demonstrate the broad range of continued training many supervisors need. Conclusions The highest priority training need for both support staff and direct service staff in rural non-profit health care and social service agencies seems to be customer/patient/client service skills. Following closely behind are basic job skills such as computer proficiency and documentation. Beyond these fundamental abilities, the trend shifts back to more interpersonal competencies such as conflict resolution and crisis intervention. Training issues for management are not quite so easily categorized or condensed. In addition, supervisory/administrative staff listed more topics as medium or high priority training needs than other staff groups. This result, coupled with the fact that staff turnover and promotion from within is the norm in rural health care and social service settings, indicates that continuous management training encompassing all areas of supervision and administrative skills is a priority training need in rural health care and social service agencies. -8- Public Health Practice in Illinois References Allegrante, J., Moon, R., Auld, M., & Gebbie, K. (2001). Continuing education needs of the currently employed public health education workforce. American Journal of Public Health, 91, 1230-1234. Gamm, L., & Hutchison, L.(2003). Rural health priorities in America: Where you stand depends on where you sit. Journal of Rural Health, 19, 209-213. Mayne, L., &Glascoff, M. (2002). Service learning: Preparing a healthcare workforce for the next century. Nurse Educator; 27, 191-194. National Commission for Health Education Credentialing (2001). Continuing Education Section. Retrieved September 6, 2004, from http://www.nchec.org Richter, D., Gimarc, J., Preston, G., & Williams, A. (2003). Implementing community-campus partnerships in South Carolina: Collaborative efforts to improve public health. Public Health Reports, 118, 387-391. Squires, A., & McGinnis, S. (2001). Critical care nursing orientation in the rural community hospital. Dimensions of Critical Care Nursing, 20, 40-46. Warren, J. (2000). Collaboration between a small rural community college and a large industrial corporation for customized training. Community College Journal of Research & Practice, 24, 667-680. Health Status Disparities among Adult Rural Illinois Minorities Saugar Maripuri, BS National Center for Rural Health Professions University of Illinois at Rockford Rockford, Illinois Martin MacDowell, DrPH National Center for Rural Health Professions University of Illinois at Rockford Rockford, Illinois For more information, contact: Martin MacDowell, DrPH, MBA, MS, Associate Professor and Assistant Director Health, Professions Education, National Center for Rural Health Professions/ RMED Program, University of Illinois at Rockford, 1601 Parkview Avenue, Rockford, IL 61107-1897; Phone: (815) 395-5579; FAX: (815) 395-5908; E-Mail: mmacd@uic.edu ccording to the 2000 Census, a substantial increase in the percentage of Hispanic residents in many rural Illinois counties has occurred since 1990 (Kandel, 2004). As revealed in a study of large populations in the United States for 17 Health Status Indicators (Keppel, 2000), significant healthcare disparities exist between racial and ethnic groups in the United States as a whole. While the results of Keppel’s disparities study point to continued and significant differences between non-Hispanic whites and minorities, little is known about healthcare disparities among minorities in rural counties. It is hypothesized that significant healthcare disparities exist among minorities specifically residing in rural Illinois. This paper concentrates on disparity issues involving adults. Because healthcare needs vary with age, disparities were investigated using several different age stratified indicators for two adult age groups: working age adults (ages 18 to 64) and seniors (ages 65 and over). Appropriate indicators for each age group were selected to examine health disparities. For mortality data, common causes of death involving each adult age group were selected as indicators of overall health status. For working age adults, the selected mortality indicators included: premature heart disease, motor vehicle accidents (MVA), and homicide. For seniors, mortality indicators included: heart disease, lung cancer, malignant neoplasms, and diabetes. Indicators involving access to care encompassed data on Emergency Medical Service (EMS) runs and hospital discharges across both adult age groups. This is an initial study of health disparity patterns among rural adult Illinois residents. It is acknowledged that a more complete health indicator assessment would include many more indicators, including behavioral risk factors, and comparison of age-adjusted rates. A - 10 - Public Health Practice in Illinois METHODS Identification and Grouping of Rural Counties To examine healthcare disparities among rural Illinois minorities, the first step was to identify rural Illinois counties. The US Census Bureau uses a method involving population density when characterizing a county as rural (US Census, 2000), while the Illinois Department of Public Health (IDPH) has categorized each Illinois county as “rural” or “urban” based on rules of classification developed by the IDPH as shown in the IDPH County Classification Map in Figure 1, (IDPH, 2003). This map utilized the IDPH definition in assigning counties to the appropriate group (rural vs. urban) and in most cases agreed with the IDPH categorization (the exception being McLean county). Next, counties were grouped into regions by geographic location. Five major geographical Rural Regions were identified among the rural counties: Northwest, East Central, West Central, Southeast, and Southwest. While the IDPH utilizes region names that correspond to major cities located within each region, in the present study geographical area names were used instead. In most of the Rural Regions, there exists at least one county with a major metropolitan area (for example, Champaign County in the East Central region). All of these counties were grouped separately in a region labeled “Other Urban,” thus excluding those urban counties from the Rural Regions. Therefore, each Rural Region includes only rural counties. The counties surrounding Chicago, also commonly called the Collar Counties, were included in a region labeled “Collar/Suburbs.” Cook County, which includes the City of Chicago, was placed in its own region, and named “Chicago.” [For a full list of counties included in each regional grouping, contact the corresponding author.] Collection of Population Data In order to calculate a rate from the events collected with each indicator, the population within each region was obtained. Using data tables available through the 2000 Census (specifically a website database called “American Factfinder” - US Census Factfinder Web Site, 2005), population data by race and age for the 2000 census year were compiled and summarized for all 102 Illinois counties, and then grouped according to the Rural Regions described previously. The identified races included White, Black, and Other, where Other is defined principally as Asians, Native Americans, and “other”. For ethnic groups, counts of Hispanics were compiled. To estimate the number of non-Hispanics in each region, all Hispanics were assumed to belong to the White race, which allowed for the simplicity of subtracting the Hispanics from the White population, resulting in an approximate estimate of the Non-Hispanic population in each region. The group labeled Non-Hispanic, included all non-Hispanic Whites Blacks, and Other racial groups. The 2000 Census provided population data in two primary age groups: 18+ and 65+ years. The compiled data from the 65 and over group was subtracted from the 18 and over group to yield an accurate indication of the 18-64 age group population for each region. Similar methods were utilized to gather population data from the 1990 Census figures. Health Disparities among Adult Rural Minorities - 11 - Some indicators required a population between Census years. Using both the 1990 and 2000 Census data and the change in population from 1990 to 2000, a yearly increment estimate was calculated in order to determine an approximate interpolated population for the required midinterval year. For example, if a population estimate was required for 1996, 3/5 of the difference between the Census years was added to the 1990 population (by race and age). Because of the limitations in some databases, when selecting an age range, some indicators required either a 20-64 age range or a 15-64 age range. The first situation (20-64) was estimated by dividing the 18-64 population by the number of ages (47), and incrementally removing two ages using that estimate. Although this method does not take into account differences seen in the Illinois population pyramid, the exclusion of a very small number of individuals from a very large group would not be expected to result in any major differences in the calculated rates for each indicator, regardless of method. A similar methodology was utilized to estimate the 15-64 age range. Selection of Indicators Using the CDC Wonder Database (Center for Disease Control Website, 2005) and the Illinois Project for Local Assessment of Needs (IPLAN) maintained by the IDPH (IPLAN web site, 2003), indicators were selected based on the availability of data and an adequate number of events in the minority groups. Because of the small number of minority residents in rural counties and thus the relative infrequency of mortalities involving that small group, leading causes of death were determined using CDC Wonder. Appropriate mortality indicators were selected for each age group (18-64 and 65+) based on common causes of death for each. Indicators involving access to healthcare, such as EMS runs and hospital discharges, were also included. A list of the present study’s health indicators and the corresponding ICD (International Statistical Classification of Diseases and Related Health Problems) codes are presented in Appendix A). Calculation of Rates For mortality indicators, events (deaths) were counted from 1994 to 1998 in each region across the racial groups. Data on mortality after 1998 was available, but a decision was made to exclude those years because of the complexities of matching the ICD code differences between 1998 and 1999: ICD-9 was replaced with ICD-10 in 1999, but all ICD codes listed in this report are based on the ICD-9 standard since the change to ICD-10 did not impact the cause of death examined in this study. Data on Hispanics were collected exclusively from IPLAN, since CDC Wonder does not report mortality data by ethnicity. In the event that Hispanic data were available, the same ICD codes were used on both IPLAN and CDC Wonder for consistency. The summated number of events from 1994 to 1998 was used to calculate the average yearly number of deaths. A mid-range population year, in this case 1996, was then used to calculate the rate (number of deaths per K population, where K is some multiple of 10). For all indicators involving working age adults, population data for the estimated 20-64 age group were used because CDC Wonder data did not include the entire 18-64 year age group. - 12 - Public Health Practice in Illinois Due to the complexities of the data, study time limitations, and the relative consistency of population pyramids between rural regions, age-adjusted rates were not calculated. It was ascertained that age-stratified crude rates closely approximated the age-adjusted rates, and statistical conclusions could safely be made from those rates alone. It should be noted that all rates published in this report are crude age specific rates. Data concerning EMS runs and hospital discharges in Illinois were collected from the IDPH EMS Data Reporting System (IDPH EMS Data Reporting System Web Site, 2003). Similar age group limitations were encountered when using this database. Specifically, EMS run data were collected in two age groups: 20-64, and 65+. For hospital discharges, the two age groups used were: 15-64, and 65+. The rationale of including younger individuals in hospital discharge rates was to be consistent with CDC published studies (NCHS, 2002), which calculated the US national discharge rate in 15-64 and 65+ age groups across a variety of different conditions. It should be noted that the EMS data posted on the IPLAN web site were used directly with no verification of the completeness or accuracy of event reporting submitted by EMS providers. For EMS run data, rates were calculated for total runs as well as runs specific for a condition, such as heart-related primary complaints. For discharge rates, a similar approach was implemented. Rates were calculated for all discharges, regardless of cause, and for discharges due to mental disorders. In order to make a comparison with the US national rate for total discharges and discharges due to mental disorders, ICD codes were matched to ensure the counting of events (discharges) was consistent between the CDC study and the present analysis. One caveat related to the IDPH EMS Data Reporting System, as noted in the documentation for the EMS database (IDPH EMS Data Reporting System Web Site, 2005), is that several years of data seemed to be under-reported as computer systems were updated. In order to avoid these inconsistent years, the EMS data utilized in this project were from 1999 to 2001 only, with a mid-interval population in the year 2000. For discharge rates, the national rate, as reported by the CDC, was obtained for 2000 and used in comparison to the average yearly rate between 1999 and 2001 in Illinois. Although problematic years in the EMS Data Reporting System were excluded because of the under-reporting of data, one must still be cautious in drawing conclusions from the results of both the EMS run data as well as the hospital discharge data because of the prior difficulties with this database. Statistical Analysis All resulting rates for indicators were analyzed at the 95% confidence level (p<.05) using a standard methodology for comparison of rates (Dever, 1991). Two different comparisons were utilized to determine the significance of difference between rates calculated from the data collected. The first, known as comparison against a state/national standard, compares the rate within a region and a specific race against the state or national rate for that race. Results for this analysis, with the exception of discharge rates, are available upon request from the corresponding author since the purpose of this study was to examine racial group or Hispanic origin status (Hispanic origin or non-Hispanic origin) differences in indicator patterns within a region. A second analysis, termed comparison between races/Hispanic origin status, compares Health Disparities among Adult Rural Minorities - 13 - the rates in a minority group against those in the majority group within the same region. In all analysis, racial groups labels provided in the data source for race or Hispanic origin were used. As defined in the data sources (CDC and IPLAN), race and Hispanic origin status are viewed as two separate concepts with the following framework: o People who are Hispanic may be of any race. o People in each race group may be either Hispanic or Not Hispanic. o Each person has two attributes, their race (or races) and whether or not they are Hispanic. For the EMS Run and Hospital Discharge indicators, an additional criterion was devised to better delineate differences between regions. Because of the very high number of events for each of these indicators, even very small absolute differences are considered “significant” based on the algorithm used. Because of this, an alternative definition of “significance” was defined based on an absolute difference of 20% for EMS Run indicators and 15% for Hospital Discharge indicators in addition to the usual significance tests at p<0.05. This “clinical” or “practical” significance criterion was added to the evaluation of differences as “significant” in this report for only two sets of indicators: EMS Runs and Hospital Discharges. RESULTS Due to space limitations, only selected information is presented in this section. [All Figures and Tables are provided at the end of the article] Motor Vehicle Accident (MVA) Mortality Among Working Age Adults: The mortality rate, Table 1A, among blacks was significantly higher when compared to the white rate within the same region in Chicago and All Urban Areas. Although it appears the mortality rates in rural regions for blacks was lower than the white rate, no conclusions can be made because of the small number of events. Homicide Mortality Among Working Age Adults 20-64: As shown in Figure 2, the homicide mortality rate among blacks when compared to the white rate within the same region was significantly higher in the Southeast, Northwest, and East Central Rural Regions. It was also significantly higher for blacks compared to whites in the Collar Counties, Chicago, Other Urban Counties, All Rural Counties, All Urban Counties, and All Illinois Counties. Premature Heart Disease Mortality Among Working Age Adults 20-64: The mortality rate, Table 1B, among blacks when compared to the white rate within the same region was significantly higher in the Collar Counties, Chicago, Other Urban Counties, All Urban Counties, and All Illinois Counties. The premature heart disease mortality rate among Hispanics when compared to the non-Hispanic rate within the same region was significantly lower in the Collar Counties, Chicago, and All Urban Counties. A graph of these rates is shown in Figure 3. - 14 - Public Health Practice in Illinois Heart Disease Mortality Among Seniors 65+: No significant differences among blacks when compared to the white rate within the same region were found - Table 1C. The heart disease mortality rate among Hispanics, when compared to the non-Hispanic rate within the same region, was significantly lower in Collar Counties, Chicago, Other Urban Counties, All Rural Counties, All Urban Counties, and All Illinois Counties (Figure 4). Lung Cancer Mortality Among Seniors 65+: The mortality rate among blacks, when compared to the white rate within the same region, was significantly higher in the West Central Rural Region, Chicago, All Urban Counties, and All Illinois Counties - see Table 1D. The lung cancer mortality rate among Hispanics, when compared to the non-Hispanic rate within the same region, was significantly lower in Chicago, All Urban Counties, and All Illinois Counties. Malignant Neoplasm Mortality Among Seniors 65+: The mortality rate, Table 1E, among blacks when compared to the white rate within the same region was significantly higher in Chicago, Other Urban Counties, All Urban Counties, and All Illinois Counties. Diabetes Mortality Among Seniors 65+: The mortality rate among blacks, Table 1F, when compared to the white rate within the same region was significantly higher in the Collar Counties, Chicago, Other Urban Counties, All Rural Counties, All Urban Counties, and All Illinois Counties. Total EMS Runs for All Causes Among Working Age Adults 20-64: The rate among blacks when compared to the white rate, Table 2A, within the same region was “significantly” higher in the Collar Counties, Chicago, Other Urban Counties, All Urban Counties, and All Illinois Counties. The rate among Hispanics when compared to the non-Hispanic rate within the same region was “significantly” higher in the West Central Rural Region and All Rural Counties. Total EMS Runs for All Causes Among Seniors 65+: As shown in Table 2B, the rate among blacks when compared to the white rate within the same region was “significantly” higher in the Northwest and West Central Rural Regions, as well as the Collar Counties and All Rural Counties. The rate among Hispanics when compared to the non-Hispanic rate within the same region was “significantly” lower in every region except the West Central Rural Region. EMS Runs Due to Heart Disease Among Seniors 65+: The rate among blacks when compared to the white rate, Table 2C, within the same region was “significantly” higher in the Collar Counties and Other Urban Counties. Health Disparities among Adult Rural Minorities - 15 - The rate among Hispanics when compared to the non-Hispanic rate within the same region was “significantly” lower in Collar Counties, Chicago, All Rural Counties, All Urban Counties, and All Illinois Counties. Hospital Discharges Among Working Ages Adults 20-64: When compared to the national rate for All Discharges, Table 3A, the rates in the Southeast, Northwest, and Southwest Rural Regions is “significantly” lower. The Chicago rate is significantly higher than the national rate. For hospital discharges due to mental disorders, the Southeast, Northwest, Southwest, and East Central Rural Regions, as well as All Rural Counties, are all “significantly” lower than the national rate. The rate in Chicago, All Urban Counties, and All Illinois Counties is “significantly” higher than the national discharge rate for mental disorders - Table 3A. Hospital Discharges Among Seniors 65+: When compared to the national rate for All Discharges, the Northwest Rural Region is “significantly” lower in discharges in this age group - Table 3B. For hospital discharges due to mental disorders, Table 3B, the Southeast, Northwest, West Central, Southwest, and East Central Rural Regions are all “significantly” lower than the national rate. The rate in Other Urban Counties and All Rural Counties is also “significantly” lower than the national discharge rate for mental disorders. DISCUSSION While Keppel’s work (2000) involving Health Status Indicators over large national populations evaluated changing trends in disparities over time, many of the observations in that study appear to apply to the sub-populations in the present study - although the present focus was mainly cross-sectional. Another study, similar in scope in comparing national rural populations to urban populations (Slifkin and Rickets, 2000), found that rural minorities faired quite worse than their urban counterparts - with substantially higher mortality rates in common health status indicators, such as heart disease and diabetes. However, the authors noted significant issues with “small cell size” within many of their data sources, which made obtaining statistically significant results difficult. While the current study established significant health status disparities among minorities in rural Illinois similar to previous national studies, many of the statistically significant differences were observed in predominately urban areas. The “small cell size” issues found in other studies seem to have resulted in very few statistically significant differences between rural subgroups and the state rate. Comparisons between race and ethnicity within a region were clearer, but urban disparities still predominated over rural disparities. The only indicators where significant differences were found among rural minority populations involved: 1) homicides among younger adults and 2) and mortality due to heart disease, lung cancer, and diabetes among seniors. - 16 - Public Health Practice in Illinois One of the major issues when studying mortality data for minority populations in predominantly white counties is the low number of minority individuals and subsequent deaths. Because of the relative rarity of a minority death even in a large aggregate region, subsequent rates for those deaths intrinsically have a very large confidence interval. Thus, obtaining statistically significant results at a 95% confidence level proved difficult. Although efforts were made to limit the statistical issues of the small number of minorities in rural Illinois counties by creating rural regions encompassing many counties, the raw population numbers were still too small to effectively use mortality as an indicator of healthcare disparities. Deaths are also less frequent due to the younger ages of immigrating minorities. EMS data for the West Central Rural Region shows an unusual pattern and further examination and validation of EMS data are suggested. One approach to rectify this issue would be to use alternative datasets that measure other areas of an individual’s overall health status. Behavioral surveys, morbidity, hospital discharges or emergency department use by race, if obtainable, would likely prove more effective at delineating true disparities among minorities in rural Illinois counties. Also, an unmeasured, yet important, attribute impacting health status is socioeconomic status. A descriptive study that does not include incidence indicators cannot differentiate between utilization differences due to: • Greater or less incidence of disease or injury in a subgroup; • Variation in measurement or reporting for a subgroup; • Less or more access to healthcare services by a subgroup due to barriers to care (e.g., financial or geographic); and • Less or more willingness to use healthcare services because of cultural beliefs about the use of health services at a given time in the natural history of a disease. For example, the reasons for the patterns with regard to Hispanics relative to other racial or ethnic groups are not known and the extent of indicator pattern variation due to each of these four factors is uncertain. In summary, the findings presented in these regional analyses suggest that substantial differences occur in health related indicators between racial groups and those of Hispanic / non-Hispanic backgrounds in Illinois. Using the health status indicators for working age adults examined in this study, black residents in many of the IDPH regions have higher mortality rates, especially for homicide. Among seniors aged 65+ disparities were found for blacks versus whites related to lung cancer and all cancer mortality as well as diabetes mortality. More specific (non mortality) health status and health care access measures are recommended when assessing minority resident health disparity issues in rural areas because of the low number of deaths that occur for a given cause. Further study of the incidence of mental health problems and utilization of treatment for mental health in rural areas is needed to ascertain whether observed hospitalization patterns are because of lower incidence or lower use of treatment services. Health Disparities among Adult Rural Minorities - 17 - REFERENCES Centers for Disease Control. “CDC Wonder Database.” http://wonder.cdc.gov/ (Accessed August 15, 2005). CDC (1981) Heat-related Illnesses and Deaths -- United States. Morbidity and Mortality Weekly Review. June 30; 44(25):465-8. Dever, Alan. (1991) Basic Statistical Measures for Community Health Analysis. In Community Health Analysis. pp 74-97. New York: Aspen Publishing. Green LW, Iverson DC. (1982) School Health Education. In Annual Review of Public Health. 3:321-38. Palo Alto: Annual Reviews. Kandel, William and Cromartie, John. (May 2004) New patterns of Hispanic settlement in rural America. United States. Dept. of Agriculture. Economic Research Service. (Rural Development Research Report; no. 99) Available at URL www.ers.usda.gov/publications/rdrr99/rdrr99.pdf (Accessed August 15, 2005). Kessler RC, Cleary PD. (1980) Social Class and Psychological Stress. American Sociological Review. 45(3): 463-78 Keppel KG, Pearcy JN. (2000) Healthy People 2000: Trends in Racial and Ethnic-Specific Rates for the Health Status Indicators: United States, 1990-98. Healthy People Statistical Notes, Number 23. Hyattsville, Maryland: National Center for Health Statistics. Illinois Department of Public Health, Springfield, IL, April 1, 2003. “IPLAN - Illinois Project for Local Assessment of Needs.” Illinois Department of Public Health. http://app.idph.state.il.us/ (Accessed August 15, 2005). “IDPH EMS Data Reporting System.” Illinois Department of Public Health. http://app.idph.state.il.us/emsrpt/ (Accessed August 15, 2005). National Center for Health Statistics. (June 19, 2002 ) “2000 National Hospital Discharge Survey.” Advance Data, Vital and Health Statistics. Number 329 Slifkin RT, Goldsmith LJ, Ricketts TC. (March 2000) “Race and Place: Urban-Rural Differences in Health for Racial and Ethnic Minorities”. North Carolina Rural Health Research Program. Available at URL: www.shepscenter.unc.edu/research_ programs/rural_program/fb61.pdf (Accessed August 15, 2005). United States Census Bureau. “Census 2000 Rural and Urban Classification.” http://www.census.gov/geo/www/ua/ua_2k.html (Accessed August 15, 2005). United States Census Bureau. “American Factfinder.” http://factfinder.census.gov/ (Accessed August 15, 2005). - 18 - Public Health Practice in Illinois APPENDIX A – LIST OF INDICATORS AND ICD CODES Indicators by ICD Code Indicator Premature Heart Disease Motor Vehicle Accidents Homicides Heart Disease Lung Cancer Malignant Neoplasms Diabetes All EMS Runs EMS Runs Due to Heart Complaints Total Hospital Discharges Discharges Due to Mental Disorders Adult/Senior A A A S S S S A/S S A/S A/S ICD Code 402, 410-414, 429.2 810-829.9 960-969 402, 410-414, 429.2 162.2-162.9 140-208.9 250 Not applicable Not applicable Not applicable 290-319 Figure 1: Rural and Urban Regions Map Figure 2: Average Yearly Mortality Rate from Homicide Among Working Age Adults Ages 20-64 In Illinois by Racial Groups and by Location, Years 1994-1998, per 100,000 Population + + + + 70.00 60.00 50.00 40.00 + + 30.00 20.00 + + + Average Yearly Rate (deaths per 100,000 population) 10.00 0.00 Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural All Urban Illinois Southeast < ---- Rural Illinois Regions -- See Map Figure A ---> Note: Rural Regions exclude urban counties. For a list of which counties are included in each region, see Appendix 1 (+) denotes that the observed difference between black and white rates within the same geographic area is statistically significant (p<.05) White Black Figure 3: Average Yearly Mortality Rate from Premature Heart Disease Among Working Age Adults Ages 20-64 In Illinois by Ethnic Groups and by Location, Years 1994-1998, per 100,000 Population 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 + Average Yearly Rate (deaths per 100,000 population) 20.00 + 10.00 + 0.00 Chicago Other Urban All Rural All Urban Illinois Collar/Suburbs Note: Rural Regional data on this indicator is unreliable due to the small number of events from each area (<1 death per year), and has thus been excluded from this figure. For simplicity, all hispanics are assumed to be "white" and caucasian rates are estimated using this assumption. Caucasian Hispanic (+) denotes that the observed difference between caucasian and hispanic rates within the same geographic area is statistically significant (p<.05) Figure 4: Average Yearly Mortality Rate from Heart Disease Among Seniors Age 65+ In Illinois by Ethnic Groups and Location, Years 1994-1998, per 100,000 Population 2000.00 1800.00 1600.00 1400.00 1200.00 1000.00 800.00 600.00 + + + + + + Average Yearly Rate (deaths per 100,000 population) 400.00 200.00 0.00 Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural All Urban Illinois Southeast < ---- Rural Illinois Regions -- See Map Figure A ---> Note: Rural Regions exclude urban counties. For a list of which counties are included in each region, see Appendix 1. For simplicity, all hispanics are assumed to be "white" and caucasian rates are estimated using this assumption. (+) denotes that the observed difference between hispanic and caucasian rates within the same geographic area is statistically significant (p<.05) Caucasian Hispanic Table 1 – Ethnic and Racial Comparison of Mortality Indicator Rates By Adult Age Groups, Geographic Regions in Illinois, 1994-98 Note: (+) indicates significance (p<.05) for “comparison against the Illinois rate”, as described in the Methods section. (*) indicates significance (p<.05) for “comparison between races (eg, White vs. Black) or Hispanic/non-Hispanic , as described in the Methods section. Working Aged Table 1A: Average Yearly Mortality Rate from Motor Vehicle Accidents Among Working Age Adults Ages 20-64 in Illinois by Racial Groups and by Location, Years 1994-1998, per 100,000 Individuals Southeast Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural White Black Other 21.25+ 20.32 12.91 23.95+ 16.12 0.00 18.48 8.61 7.42 29.15+ 11.28 0.00 19.39 4.74 3.61 13.43 18.20 4.24 12.36+ 17.83* 2.51 15.99 17.35 5.22 21.60+ 12.37 5.45 All Urban 13.50+ 17.81* 3.04 Illinois 15.34 17.55 3.12 Table 1B: Average Yearly Mortality Rate from Premature Heart Disease Among Working Age Adults, Ages 20-64 in Illinois by Racial Groups and by Location, Years 1994-1998, per 100,000 Individuals Other Southeast Northwest West Central Southwest East Central Collar/Suburbs Chicago Urban All Rural White Black Other 77.55+ 80.01 21.52 65.69 59.10 8.56 61.32 34.44+ 7.42 66.82 56.39 0.00 59.19 64.77 7.22 43.32+ 58.80+* 8.02 69.18+ 54.49 66.13+ 62.25+ 9.99 122.35+* 77.11+* 8.52 7.55 All Urban 57.47 111.48* 8.36 Illinois 59.44 109.15 8.41 Table 1C: Average Yearly Mortality Rate from Heart Disease Among Seniors Age 65+ In Illinois by Racial Groups and Location, Years 1994-1998, per 100,000 Population Southeast White Black Other Seniors Table 1D: Average Yearly Mortality Rate from Lung Cancer Among Seniors Age 65+ In Illinois by Racial and Ethnic Groups and Location, Years 1994-1998, per 100,000 Population Southeast White Black Other Non-Hispanic Hispanic 347.40 321.54 0.00 Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural 308.26 327.69 0.00 315.94 677.97* 0.00 326.19 334.45 0.00 344.15 377.57 157.36 322.02 393.31 66.21 314.51 395.81* 72.68 345.43 433.44 95.56 330.36 387.87 33.94 All Urban 323.72 399.62* 72.42 Illinois 325.57 399.26* 71.22 1597.3 1568.7 245.5 Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural 1247.7+ 873.8 151.6 1527.2 1510.0 389.1 1698.2+ 2118.2 556.6 1481.6 1057.2 393.4 1429.0+ 1446.0 370.2 1703.0+ 1660.8 403.2 1401.7+ 1309.7+ 259.4 1531.0 1426.7 322.4 All Urban 1563.8 1613.8 391.5 Illinois 1554.7 1608.1 389.3 348.01 145.88 310.53 146.25 317.40 92.28 326.87 115.47 344.98 139.18 328.37 89.36 330.04 98.26* 346.87 183.92 331.48 124.22 333.78 101.11* 333.12 102.18* Table1E: Average Yearly Mortality Rate from Malignant Neoplasms Among Seniors Age 65+ In Illinois by Racial Groups and Location, Years 1994-1998, per 100,000 Population Southeast White Black Other 1190.4 1383.6 245.5 Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural 1127.6 1474.6 0.0 1167.8 1540.8 194.6 1179.9 1672.2 0.0 1191.6 1397.0 314.7 1189.1 1405.5 276.9 1217.2 1436.0* 336.1 1174.4 1530.4* 423.2 1175.7 1440.0 169.7 All Urban 1200.1 1444.4* 328.9 Illinois 1193.3 1444.2* 323.9 Table 1F: Average Yearly Mortality Rate from Diabetes Among Seniors Age 65+ In Illinois by Racial Groups and Location, Years 1994-1998, per 100,000 Population Southeast White Black Other 135.33 243.59 0.00 Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural 144.80 273.07 0.00 133.23 246.53 129.70 121.54 222.97 0.00 137.83 245.42 0.00 127.80 257.39* 48.15 138.44 202.27* 60.10 128.37 250.17* 122.87 134.20 All Urban 133.43 Illinois 133.64 211.00* 59.62 245.21* 209.93* 33.94 60.44 Table 2 – Ethnic and Racial Comparison of EMS Run Rates Geographic Regions in Illinois, 1999-2001 Note: (+) indicates significance (p<.05) for “comparison against the Illinois rate”, as described in the Methods section. (*) indicates significance (p<.05) for “comparison between races (eg, White vs. Black), as described in the Methods section EMS Run Indicators Table 2A: Average Yearly Rate of EMS Runs for All Causes Involving Adults Ages 20-64 in Illinois by Racial and Hispanic Status Groups and by Location, Years 1999-2001, per 1000 Individuals Southeast White Black Other Non-Hispanic Hispanic 47.06 54.20 93.30 Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural 20.33 27.65 12.11 44.56 49.71 219.57 42.25 35.49 74.52 28.64 32.56 26.28 17.76 52.07* 13.88 21.09 59.97* 31.34 40.80 68.26* 126.96 38.37 43.00 86.80 All Urban 24.20 60.22* 32.71 Illinois 27.43 59.32* 34.59 47.22 36.19* 20.54 17.12 42.28 124.50* 42.53 19.13* 28.85 19.47* 17.97 16.45 21.51 20.28 41.26 29.19* 38.02 51.94* 25.35 19.76* 28.72 20.87* Table 2B: Average Yearly Rate of EMS Runs for All Causes Involving Seniors Ages 65+ in Illinois by Racial and Hispanic Status Groups and by Location, Years 1999-2001, per 1000 Individuals Southeast White Black Other Non-Hispanic Hispanic 231.92 187.87 696.86 Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural 95.97 614.04* 81.36 183.07 251.18* 1,246.63 213.77 229.91 554.57 139.53 99.91* 137.57 104.73 180.24* 120.71 99.77 116.46 185.65 185.56 179.36 1,061.99 181.50 217.11* 560.35 All Urban 121.77 126.23 208.15 Illinois 138.33 128.82 218.61 232.42 85.78* 96.60 56.34* 182.61 245.33* 214.28 51.72* 139.93 48.99* 106.28 56.51* 103.09 61.84* 186.44 96.22* 181.86 122.92* 124.91 62.57* 141.22 65.24* Table 2C: Average Yearly Rate of EMS Runs for Heart Related Illnesses Involving Seniors Ages 65+ in Illinois by Racial and Hispanic Status Groups and by Location, Years 1999-2001, per 1000 Individuals Southeast White Black Other Non-Hispanic Hispanic 26.12 17.37 66.43 Northwest West Central Southwest East Central Collar/Suburbs Chicago Other Urban All Rural 11.51 16.71 21.47 22.75 31.40 66.47 29.80 27.35 0.00 17.61 8.86 11.64 8.99 12.46* 4.44 7.15 3.35* 13.89 19.84 15.85* 102.88 22.38 18.10 38.17 All Urban 10.69 5.11* 15.63 Illinois 13.93 5.48* 16.29 26.17 11.94 11.59 6.26 22.72 25.99 29.89 0.00 17.68 0.00 9.12 4.94* 7.48 3.29* 19.91 13.16 22.44 12.32* 11.05 4.02* 14.31 4.38* Note: As discussed in the methods section, several years of data are known to be under-represented within the EMS Run Database. These years have been purposely excluded from this analysis, but the legitimacy of the 1999-2001 reported data must be approached cautiously. Note that significance in this table includes an absolute difference criterion for all indicators. See the Methods section for details. Table 3 – Comparison of Mental Disorder Hospitalization Indicator Geographic Regions in Illinois, 1999-2001 Rates, Hospital Discharge Indicators Note: No racial data was available through IDPH for the hospitalization indicator. Table 3A: Average Yearly Rate for All Hospital Discharges and Discharges Due to Mental Disorders Among Working Age Adults Ages 15-64 In Illinois and USA by Location, Years 1999-2001, per 10,000 Population Southeast Northwest West Central Southwest East Central Collar/Suburbs All Discharges Mental Disorders 769.2+ 63.2+ 764.0+ 47.0+ 870.4 81.0 713.8+ 62.2+ 849.2 71.1+ 869.7 83.4 Chicago 1,107.1+ 167.2+ Other Urban All Rural All Urban 826.5 96.2 804.9 67.6+ 987.4 130.0+ Illinois USA 953.9 924.3 118.6+ 95.6 Table 3B: Average Yearly Rate for All Hospital Discharges and Discharges Due to Mental Disorders Among Seniors Ages 65+ In Illinois by Location, Years 1999-2001, per 10,000 Population Southeast Northwest West Central Southwest East Central Collar/Suburbs All Discharges 3,400.9 2,926.0+ Mental 47.7+ 39.3+ Disorders 3,635.1 62.7+ 3,606.3 64.7+ 3,536.0 58.1+ 3,843.5 88.8 Chicago 3,976.0 97.1 Other Urban All Rural All Urban 3,274.5 69.7+ 3,470.0 3,794.6 55.6+ 89.3 Illinois USA 3,715 3,595 81.1 85.1 What Do Consumers Say About Locally-Provided Health Care in Rural Illinois? Results from a Focus Group Study of Community Perceptions Paul E. McNamara Assistant Professor, Department of Agricultural and Consumer Economics, University of Illinois at Urbana—Champaign, and Extension Specialist, Consumer Economics and Health Economics, University of Illinois Extension L. Kathleen Brown Extension Educator, Community and Economic Development, University of Illinois Extension mall and mid-sized hospitals in rural Illinois face a number of challenges in their operating environments, including financial pressures originating with low reimbursement levels for the Medicaid and Medicare programs, difficulties in bargaining with large insurance plans, as well as staffing shortages in critical areas. Despite these challenges, small-city and small-town hospitals continue to adapt and improve their services in their mission to provide health care services that are essential to the quality of life in their communities. One component of the strategic management process for rural hospitals and their communities is gauging consumer perceptions of their operations in their local communities. To assist one rural Illinois hospital in its mission to serve its community’s health care needs, the Illinois Rural Health Workshop conducted a focus group study of consumer perceptions of locally-provided health care. This paper reports the results of the study and draws conclusions for the strategic planning process of the rural hospital as well as for public health and others interested in access to health care services in rural Illinois. Methodology To learn how Oak County residents perceive their local health care system, a series of eight focus group sessions were held.1 Oak County has between 25,000 and 50,000 residents and is known for its institution of higher education and vibrant production agriculture, social services and health care, and its comparative isolation from the major cities in Illinois. Relative to urban counties in Illinois, Oak County has fewer local health care services and providers. For example, in 2001, the County had one hospital and a ratio of roughly 700 people per active physician. In terms of industrial structure, the county has a disproportionate share of white collar workers (55 percent of workers) and health care and social service workers (35 percent of workers) compared to other rural counties in Illinois with a USDA ERS Rural/Urban Continuum Code of 5 or more. The name of the county and other geographic identifying information have been changed in this paper to protect the identity of the hospital facility and the participating rural residents. The county will be referred to as Oak County, Illinois. 1 S - 28 - Public Health Practice in Illinois This group of 57 rural Illinois counties had an average of 49 percent white collar workers and 21 percent health care and social service workers. The focus group discussions were designed to gather information about community views, experiences, and perceptions of locally-delivered health care from a set of residents with differing occupations, income levels, ages, and health care needs. The discussion questions posed in the sessions are provided in Appendix A. The authors developed the questions with input from the local hospital management team. The criteria used for the selection of questions was how the questions and their responses might inform the hospital’s understanding of different views of the local health care system that were held by Oak County residents. The purpose of focus group research is to gather qualitative information about the attitudes, perceptions, and opinions of session participants (Krueger, 1988). From the statements made at focus group sessions, the analysts can identify themes across the different participant responses. Hospital managers and community health planners can utilize this information as they shape the delivery of health care in a community and develop a hospital’s strategic plan. Users of focus group information should keep in mind that focus group research does not lend itself to the quantification of relationships or to formal statistical testing of hypotheses. Instead, the strength of focus group research information is in gathering and organizing information about participants’ views on an issue, program, service, or policy. For this reason, techniques like focus group sessions, in-depth interviews of key informants, and other open-ended qualitative methods to gather community input, are often used in community health planning exercises. Each of the focus group sessions ran for 90 to 120 minutes and included between four and twelve participants. Participants were recruited through local organizations and affiliations (including the Oak County Human Resource Association, funeral home directors, the ministerial association, schools, public housing, manufacturing companies, and employee newsletters). In all, over 50 people participated in the sessions, including retirees, business people, service and manufacturing employees, human resource managers, ministers, and working mothers. Some participants faced special health care needs or had recently used Oak County Hospital or another hospital, while others faced no particular health care needs. Also, some participants had children and others did not. All told, the participants formed a relatively diverse cross-section of Oak County residents. The authors facilitated the focus group sessions with a purpose of keeping the discussion “on question” and allowing differing opinions to be heard. Questions that probed and sought to clarify statements were used to explore participant opinions of the Oak County health care system. The sessions were taped, transcribed, and then analyzed. Krueger’s (1988) guidelines for analyzing focus group transcripts were followed: all the focus group transcripts were read, and then each question was examined across the focus group results. The focus group results yielded a unique and detailed portrait of how local residents perceive the Oak County health care system. Community Perceptions - 29 - Focus Group Results The participants voiced a wide variety of opinions concerning locally-available health care and the Oak County Hospital. Overall, some common themes that were heard repeatedly included the importance residents place on quality health care services, especially primary care and emergency care, available locally in Oak City. Given the relative isolation of Oak County and the distances to other larger cities, participants expressed their appreciation for the services available in Oak City, and in particular, their appreciation for the presence of the hospital and its services. Another overarching theme that emerged was the importance that resident’s place on communication with their health care providers and the extent to which patient/provider interactions shape resident perceptions of quality of care and service. A third general theme identified from the discussions was the way perception of the health care system varied depending on social, economic, and demographic factors. In what follows, the results of the focus group discussions are presented and analyzed, with the most common themes identified as well as divergent opinions that may deserve consideration in health planning processes. Table 1: Oak County Health Care Strengths Quality/Accreditation Local access/convenience/local hospital/available services Emergency Services/Rescue Squad/Ambulance Hospice Therapy/Rehabilitation Services Services for Seniors/AAA/LTC/home care/Alternatives Caring and compassionate nurses, physicians, hospital staff, and other providers Cooperation and collaboration between hospital and other local health and civic organizations County Health Department – WIC, screenings, testing, inoculations, services for low-income people Technology and the way the hospital is working to stay current Recruitment of physicians and other health care providers and the role of the hospital in this Affiliations and relationships with providers in larger cities County mental health/behavioral health Women’s Center Connections and familiarity with health care providers Education/safety/prevention programs Oak County Health Care Strengths As Table 1 indicates, focus group participants identified a large number of strengths and assets of the health care system in Oak County. The most frequently mentioned strengths were local access to a hospital and other health care services, presence of emergency services, quality health care, and caring and compassionate providers. Other strengths that were mentioned at least several times included hospice, services for the elderly, the role of the hospital in drawing physicians and other health care professionals to the area, personal relationships and connections - 30 - Public Health Practice in Illinois with health care providers, and the way local health care organizations cooperate (hospital, public health, senior services, etc.). Many participants reported that they were very appreciative of the presence of locally available primary care, emergency care, and the hospital. In response to the question “What do you see as the most important strengths of the healthcare system in Oak County?” many participants responded that the most important strength was the “hospital close by” that is “very accessible and very handy”. Another participant remarked “I think the most important strength is that we have a hospital.” One comment that was repeated in several different sessions was, “I feel like we are blessed in this very rural area to have those kinds of facilities available.” Focus group participants also reported that the availability of quality emergency medical services is a strength that is very important. One participant stated, “…the fire department and the ambulance service I have always found them to be very timely and have great service. And I certainly have never heard any complaints about it.” Another participant remarked, “…our big asset is the rescue squad. We have a tremendous rescue squad. It is very good and they are striving to do better all the time.” Another strength of the local health care system that focus group participants identified was the care and compassion displayed by physicians, nurses, and other local health care professionals. One participant related the following anecdote as a way to explain his assessment that the Oak County Hospital staff was very caring in the manner that they delivered their services: “Because they are a rural, more intermediate-sized hospital, the personal connection that the patients and families feel is there. We’ve had an experience with a hospital in …[a larger city], where there was no comparison to the way we as a family felt comforted when my father was here [at Oak County Hospital] for an extended stay six years ago. And my mother had been at one of the hospitals in …[a larger city] for about a month, and no one ever asked us or wanted to listen to any of the concerns of the family.” A local minister echoed this theme, stating: “One afternoon I was visiting with a patient, an elderly lady who was really sick…we were talking and normally it’s my standard procedure when a doctor or nurse comes in the room I politely say “I’ll be back…” This time the doctor said, “No sir, you stay, I’ll leave.” I couldn’t believe it. It’s not that I don’t have any respect for a doctor, but it’s the fact he took the time to say, “Hey, what you are doing is important too”…If I need an operation I want him to do it. And the nursing staff, they are outstanding with their kindness.” Changes Participants Would Like To See Focus group participants also discussed things they would like to see changed in the local health care system. Table 2 lists the themes identified from the focus groups concerning areas in which consumers would like to see change. Community Perceptions - 31 - Table 2 Key Issue Areas Identified for Change Broaden recruitment of health care providers Case management services for chronic conditions Choice in physicians Communication Confidentiality/privacy issues Create positive community stories Diversity of gender and race in health care providers Free clinic Insurance Perceptions of quality Prompt care center Timely response with screening services Availability of health care and difficulties in scheduling appointments or in delays was a theme that was mentioned multiple times. A longstanding rural health challenge has been the struggle to recruit physicians and other health care professionals. While many participants recognized the hospital’s dedication and success in the areas of physician recruitment, there were numerous stories of lengthy waits for screening appointments and physician appointments, emergency room waits, and waiting in physician’s office. As one woman mentioned, “It is frustrating at times, I know, just to get in for a regular yearly exam, you almost have to make those a year in advance, at least two to three months in advance.” Another focus group participant related that: “Even though I had planned several months in advance for my mammogram, because I was conscientious enough to cancel as soon as I discovered a work conflict about a month ahead of my appointment, I had to wait another month. As a woman, that bothered me that I was putting off my annual for one more month. There’s really a backlog in that department.” Delays in scheduling were mentioned as was frustration with waiting times in the physician’s office. As one participant stated, “sometimes you just think I don’t have time to go to the doctor because I can’t spend all that time waiting.” The desire of Oak County residents for additional health care choices was another key theme identified in the focus group responses. While rural residents often live in rural areas because they are consciously trading the broad spectrum of services available in urban areas for the relative tranquility and simplicity of rural life, as health care consumers they still want choices when they have an important health care issue. Participants generally spoke about the need for additional choices in health care services when they had difficulty accessing a service, dealing with particular personalities, and limitations imposed by cost of health care services and insurance. As one participant put it, “First of all, I think people like to have a choice. If there is only one person, and if there is a negative perception, whether it is valid or not, you know, that word gets out.” - 32 - Public Health Practice in Illinois A number of participants expressed a desire for more choice in women physicians or physicians of color. As one woman put it, “We need female physicians.” Other participants stated a desire for a sufficient number of primary care physicians. For example, one participant said, “If anything, just keeping a proper number of family care, general care physicians is important.” A number of participants expressed a desire for a Prompt Care Center where minor emergencies could drop in and be seen in a short amount of time and not wait behind more complex cases to be seen. As one person stated, “most of the cases that I know, people that have gone to the emergency room could have been handled by a Prompt Care Center.” A number of people (people living on limited resources and others) described a wish for more options for low-income people, especially those without health insurance. As one participant stated, “it would be nice if we had a free clinic around here. Cause there are people like me that are in between. I can’t get the medical card, can’t get disability, and I am not a senior citizen. And you know with a very limited income, it is real hard to go to the doctor.” An additional dimension of desired choice mentioned by some focus group participants was in the area of insurance companies with coverage through their cheapest plans in Oak County. As one human resource professional put it: “It’s very, very difficult to get insurance quotes with network access for Oak County. It’s virtually impossible. There just aren’t any providers. My employees, the group that I get the insurance for, I have … [Oak County and three other larger counties]. And my Oak County employees are the only ones that do not have network access. However, I do have several Oak County employees that are going to … [nearby larger towns], and those places to utilize the network doctors because it only costs them $5 visit instead of having to pay the $50 up front and then send the form in and wait for the insurance company to send the money back because the doctors won’t file their insurance papers for them.” Determining quality of health care is a difficult process, even in the simplest, most contained system. Health care is not a discrete product; instead, it is composed of the activities of a large number of different types of health professionals. Quality is assessed not only by whether the patient lives or dies but also by the availability of providers, their technical skills, the quality of the personal interaction between doctor and patient, and the health care organization’s flexibility and responsiveness to the unique needs of individual patients. Quality of health care emerged as a major theme in areas that needed improvement in Oak County’s health care system. These concerns ranged from perceived medical errors to poor communication and unprofessional conduct by staff. For instance, one participant mentioned how “I have hit just very recently a couple of situations where I could see these becoming negative situations. And both of them probably seemed to be things in which people should have been referred and weren’t.” Communication concerns were mentioned a number of times by focus group participants. Referring to local doctors, one person stated, “I think they don’t take the time that’s needed and I Community Perceptions - 33 - think they don’t listen.” Participants perceive the time pressure their providers are under and are frustrated by the brief interactions they have with their doctors and other health care professionals. One man, talking about his wife and her health care, expressed a desire for a more relaxed interaction with her physician: “So, I attributed that to the lack of communication. My wife said she made her feel like she did not want to touch her, really, or talk to her. She would get her in, whisk her out. No follow-up calls. Nothing.” Privacy was another important dimension of health care quality. Overall, the main concerns expressed centered on shared rooms at Oak County Hospital. (Only a few participants expressed concerns about hospital staff sharing personal information inappropriately.) An example of a privacy concern is expressed by the statement: “A young girl was admitted to my room in the hospital. She had attempted suicide. The next day her doctor came in and discussed her whole life with her in the room, with me in the other bed.” A related concern was how the physical layout of the hospital sometimes failed to lend itself to maintaining privacy. One participant mentioned that “checking into admission at the hospital, that’s not very private.” Another participant stated, “…the surgical area waiting room was too small since they remodeled. You really are right on top of each other when the families are waiting for surgical patients. There is no way that you can talk in there without having everybody in the whole room hear what is going on.” Another dimension of quality was the conduct of hospital staff and doctor’s office staff. One woman related about how her husband had gone into Oak County Hospital for a procedure, and had difficulties with the staff person who was explaining the procedure to him and not being satisfied he left the hospital before the procedure was completed. As the participant stated, “While he was talking to her she was standing there, had gum in her mouth, and started pulling the gum in and out. It was just terrible. They blew everything. And he just came out of that experience saying that ‘I am never going back to that hospital again...’ And I think just the symbol of the whole thing was the girl standing there pulling the gum in and out of her mouth. So, it was really, really unpleasant.” During the discussion about things people would like changed about the local health care system, some participants cautioned that negative health care stories circulate quickly but that positive ones are not heard. One person said “You know, because this is a small community and they tell me and I am going to tell her, she tells someone else, and before you know it, it is public knowledge…one mistake they hear it from here to New York.” Another focus group participant suggested: “You hear negative things, but then you don’t hear certain things. So, if in the way the hospital publicizes more what is done there frequently that could increase the trust of a lot of people… that way we know certain services are being offered. Bring in the human factor. On a routine basis, not too frequently, but remind the community that this is a group of people. It’s not just this cold building of technology.” - 34 - Public Health Practice in Illinois Overall, the participants emphasized the importance of clear, respectful communication with patients on the part of health care providers. A consistent theme that was heard was of busy health care professionals not having the time to listen in the manner the patient expected. As one participant put it, “The office staff, as well as the doctor, just wasn’t spending much time, or, you know, showing extra concern.” Perhaps a statement by one participant summarizes the feelings that were expressed, “You want to feel that you are more than your insurance card.” Comparison of Oak County Health Care with Health Care Elsewhere When the discussions shifted to the topic of how health care in Oak County compares with health care in other places, a wide variety of responses were heard. Some people expressed negative comparisons between local health care and that available elsewhere. However, once the comparison was made with other small cities of around 20,000 people, most of the comments display an assessment that what is available in Oak City is as good as or better than what is available in comparably-sized towns. For example, one participant stated “I think that Oak City, that the facilities are excellent. I think that Oak County Hospital probably compares favorably with larger communities as far as the services they do provide.” Another participant said, “I have lived in similar-sized communities pretty much all over the country. I’d have to rate them better than the similar-sized communities elsewhere. I mean, the facilities are better. I think the care providers are better than those in the other communities of ten to twenty thousand that I’ve lived in.” Another participant related that “Compared to …and…[two nearby small cities], I think we get really good care.” In speaking about the hospital, a participant said “for our sized town, I think the facility is next to none.” Overall the participants made a favorable comparison of the local health care with what is available in other small cities as the following comment shows “For a community this size, there are services in place…I think Oak City offers a lot of services that are very accessible.” Differences in Access A portion of the discussion explored whether participants felt that access to health care in Oak County varied by age, income, type of insurance or any other factor. Generally, participants felt that the elderly had a pretty good set of services available to them. Low-income people or people living on limited resources faced challenges in obtaining health care services, according to many of the participants. As one participant reported, “I definitely know there’s not as many choices available to people who have Medicaid.” Overall, focus group participants recognized that people that are not on Medicaid but that are low-income face particular challenges. One person stated, “I can’t get the medical card [Medicaid], can’t get disability, and I am not a senior citizen. And you know, with a very limited income, it is real hard to go to the doctor. They won’t see you unless you have the cash right there.” Another participant expressed: Community Perceptions - 35 - “The people that are just on the other side of that [qualifying for Medicaid], that don’t qualify, don’t have insurance, don’t have any access. I am aware of people that don’t have any money to have access and are not able to go to doctors and things. So it is a struggle. How do you help those people who have some of those needs?” However, a few participants felt that health care options were available for people on limited incomes, but that poor people do not use the programs or take advantage of the available services. As one participant stated, “The resources are there…I believe that most people should be aware of them…Whether they choose to use them or not, at some point, becomes a personal choice and perhaps bad decision—making on their part.” Another concern about access differences that some participants mentioned was how the quality of health care received by people with no insurance is poor. One participant stated, “I think one of my employees lost one of their children because they had no health insurance just this past year. The diagnosis and the care were not as thorough because there was no insurance and they had no method to pay on a very large or very timely scale and for that reason too, because of the way this person is they maybe neglected doing more about it, thinking it would go away or you know, they weren’t as persistent as they probably should have been.” Many participants expressed a concern that access to oral health services is a major problem for low-income people in Oak County, including senior citizens on limited incomes and for people with Medicaid insurance, “dental traditionally in this town has been the hardest…” Additional Perspective on Oak County Hospital As reported above, focus group participants were generally positive about Oak County Hospital and its services. Overall, strong support exists for the hospital and its care. Indeed, some participants felt the hospital deserves greater financial support from the community. One participant stated: “Why don’t they go ahead and tax? I know people start shuddering about that, but I personally would rather they tax…just like you do for the fire department and hope you never need them, but feel secure in knowing they are there. I’d rather pay that than the one for the airport for sure.” However, along with the strong support, a number of additional issues concerning difficulty in using the hospital or areas where participants felt that services could be improved were mentioned. Human resource professionals mentioned difficulties in using the hospital because it and its physicians are not in some networks. Comments included, “Our hospital is one that is known in the insurance industry as having a void for being in networks” and “There are very few preferred provider networks in Oak County. It’s very, very difficult to get insurance quotes with network access for Oak County. It’s virtually impossible.” - 36 - Public Health Practice in Illinois For Oak County residents with insurance plans with a provider network that does not include Oak County Hospital, using Oak County Hospital results in significant out-of-pocket expenses. As one participant put it, “Because our insurance uses those places in the network and so they pay a $5 co pay and nothing when they go in the hospital, whereas if they go to Oak County Hospital…we have a $100 deductible for being out-of-network and then it is 80/20 up to $3,000 out-ofpocket. So which are you going to chose?” The chaplain situation was another concern about Oak County Hospital raised by focus group participants. While many people understood the need to trim services because of hospital cost pressures, some felt that the manner in which the chaplain position was eliminated was not the best. Others felt that the chaplain position was necessary to the proper functioning of the hospital. As one participant stated, “I know there are a lot of people upset with letting the chaplain go and that think it was a bad decision because there are a lot of unchurched people.” However, ministers participating in the focus group sessions reported that the hospital had been working with local clergy to develop a system where ministers can assist at the hospital. They expressed their interest in the program and their desire for clear communication about the program and its development. A few focus group participants felt like the hospital facility required updating and improvements. One person stated: “I think the building looks a little tired, and when you are sick, aesthetics can make a big difference in your outlook. Like I said, I don’t have any questions about the quality of care on this level, but compared to some of the other institutions in the area, it is a little dated.” Understaffing, especially with respect to nurses and nursing services was brought up by some participants. One participant felt that the lack of adequate staff required him to be at the hospital to be with his mother and help take care of her. He said, “My mother was hospitalized when she had a broken arm and they would wheel food up to her, but she couldn’t eat. And so, it meant that I had to be there all the time because she wasn’t being taken care of. They would bring her clean clothes and they just kept piling up on a chair. I don’t blame the nurses because they were kind and they were good to her as much as they could be, but they didn’t have any help. It was just clear that there was just not enough help to get the work done. And it was two different instances in the last three or four years.” Overall, participants related about how their interactions with hospital physicians, nurses, and other staff was the primary factor shaping their opinions of the services they received. The focus group participants placed great importance on knowing that their health care provider really cared about their well-being. As one participant put it, “I think that half the battle with any doctor or hospital that you go to is the relationship you have with the doctor -- whether you feel like he cares you are going to get well or not.” Community Perceptions - 37 - Oak County Hospital Emergency Room Focus group participants reported overall satisfaction with the emergency room services at Oak County Hospital. As one participant stated, “I’ve never had anything but positive experiences with the emergency room. I was treated very professionally.” Others stated that they felt like the time it takes to be seen is reasonable and that compared to other hospital emergency rooms, the waits were comparably short. One participant said, “I grew up in the Chicago area and you never see the crowds in the [Oak County Hospital] emergency room that you see up there…wait six, seven hours to get in just to see someone.” The negative comments heard about the emergency room included complaints about the waiting times, and poor communication between staff and waiting people and their families. Oak County Hospital Testing and Screening Services With respect to testing and screening services, participants emphasized the value they place on clear communication and prompt notification of testing results. Focus group participants expect a quick answer with the test result. One participant stated, “In my case, they found several masses there and we went to the sonogram right away and they spent a long time there…certain spots she would really stay around and look and look. And then they sent the results to my doctor.” Another participant said, “I had cancer and after the treatment…I went in and got the blood test and then went over to x-ray and they were great like that. I think that between the hospital and the health department there is access to screening and testing for people.” Some participants mentioned difficulties scheduling screening exams and tests. One participant mentioned that “My husband had problems getting his MRI.” Oak County Hospital Obstetrics Overall, participants expressed positive comments about the Oak County Hospital obstetrics services. One man reported that in the case of his wife’s C-section at the hospital “the care was great. Those people care.” Some other participants felt that the quality of care was poor and that the bedside manner of some physicians was poor. Another negative aspect that was mentioned was that the rooms were shared and that just after having a baby, privacy is important for a family and the mother. Other Services People Would Like to See When asked about what other services the participants would like to see, a walk-in clinic topped the list. One participant stated, “A walk-in clinic would be great because sometimes you call and just try to get in and they have to reschedule several weeks away.” Another desired service that participants mentioned was additional services for cancer patients, such as a cancer clinic. As one participant said, - 38 - Public Health Practice in Illinois “Another item might be a cancer clinic. I’ve got several members of the congregation that once they are diagnosed must drive to …[nearby city] five days a week. And as they’re receiving radiation and/or chemotherapy their ability to make that trip continues to diminish to the point that they have to have somebody drive them. They are just too weak to do it. If we had something locally that would be a big benefit.” A third desired service that was mentioned was a case management program for assistance to employee groups on chronic disease management. One participant from industry stated, “With the costs spiraling so much out of control, one thing that came out of recent workshop was case management on chronic diseases and catastrophic illness. …employee assistance program for factories that would pay so much per employee and that allows our employees to access services.” Conclusions The focus group sessions yielded a rich portrait of Oak County residents’ views on the local health care system and Oak County Hospital, in particular. The most commonly heard themes were the high value that participants place on locally available hospital services, the importance of communication between patients and providers, and the way economic, social, and demographic factors affect Oak County residents’ views of the local health care system. These focus group results can be used as an input into the hospital’s strategic planning process or to help target and focus quality improvement efforts. Reference Krueger, R.A. (1988). Focus Groups: A Practical Guide for Applied Research. Newbury Park, CA: Sage Publications, Inc. Community Perceptions Appendix A: Focus Group Discussion Guide 1. 2. What do you see as the most important strengths of health care in Oak County? What particular experiences or aspects of the local health care system do you appreciate most? - 39 - What aspects of the local health care system would you like to see changed? (access, quality, and staff) What specific aspects of the health care system would you like to see changed? How would you change them? Are you familiar with other communities and their health care services? How does Oak County compare with other similar sized counties in Illinois or neighboring states in terms of health care? Have you had experiences with other communities? How did those experiences compare? How do you perceive access to health care in our community? Are there differences in access for different kinds of people in the community? (single parents, shift workers, elderly people, minorities, uninsured people, people with limited financial resources, students, women) How significant are these differences? Have you observed differences in access personally? What types of issues or experiences have you seen? What is your perception of Oak County Hospital? Have you had a specific experience that shapes your perception of the hospital? How would you compare Oak County Hospital with other hospitals in the region? How do you think the community perceives the hospital? Have you spoken with others about their experiences with the hospital or spoken with people about their perceptions of the hospital? How do you think community members would compare the hospital with other hospitals in the area? What is your perception of the Emergency Room services at Oak County Hospital? What are you personal experiences? What is your perception of the Emergency Room services at Oak County Hospital? What are you personal experience using the ER? Were you greeted promptly? Did you have to wait long to be seen by a nurse? By a Doctor? Did the staff seem attentive? Did they answer your questions? If you were nervous, did they help relieve the pain? What is your perception of the health testing and screening services available at Oak County Hospital? Have you utilized these services? What was the nature of your experience with the staff during your tests? Can you suggest ways that your experience might have been improved? What is your perception of the obstetrics services at Oak County Hospital? Do you know someone who has given birth at Oak County Hospital? How would they describe their experience? What is the perception of the obstetrics services at Oak County Hospital in the community? Do you know people who have chosen to give birth at another hospital in the region? Can you describe their thinking and reasons as to why they received their health care in a different hospital? What is your perception of orthopedic services? Is there a need for additional services? 3. 4. 5. 6. 7. 8. 9. 9. 10. What services would you like to see offered at Oak County Hospital? Community Health Mapping: Participation, Collaboration, and Positive Outcomes Heather McIlvaine-Newsad, PhD Illinois Institute for Rural Affairs Western Illinois University Macomb, IL Mary Jane Clark, RN, MS, CHES Illinois Institute for Rural Affairs Western Illinois University Macomb, IL H ealth has always been a priority for rural people, but expectations of what improved health might bring to both individuals and communities is greater than it ever has been before. Accompanying the expectations of better health is a high price tag and seemingly shrinking pool of resources to accomplish the task at hand. Community Health Mapping (CHM) is an innovative and cost effective health program that builds on established social networks in rural communities. The CHM program assists rural populations in identifying their health care priorities and mapping out a plan for achieving them. In this paper, we provide (1) a background of the need in rural Illinois for grassroots initiated rural health care programs, (2) present an overview of the program and explore its collaborative nature, and (3) discuss some of the long term benefits to communities participating in the program. Crisis in Rural Health Sixty-six of the one hundred and two counties in Illinois are classified as non-metropolitan or nonmetro counties. Residents of rural Illinois are faced with a “double jeopardy” situation when it comes to health care. First, the health care needs of rural residents exceed those of their urban counterparts, and second, the resources to address those needs are usually inadequate. Historically, residence in a nonmetro county in the United States has been associated with poorer health for people of all ages. According to Carlson, Lassey and Lassey (1981), in the 1980s rural populations suffered from higher rates of infant mortality, motor vehicle crashes, and workrelated injuries than did their urban counterparts. Some 20 years later, nonmetro counties in the southern and western parts of the United States continue to report high rates of infant mortality (Eberhardt et al. 2001). Agriculture – a driving economic force in rural Illinois - ranks among the most hazardous industries for occupational mortalities and injuries (Rautianen and Reynolds 2002). In 2000 the fatality rate for the agricultural industry was six times the national rate, or 22.5 deaths/100,000 workers (Schulman and Slesinger 2004). - 42 - Public Health Practice in Illinois The obstacles facing rural residents in obtaining affordable and accessible health care are also complex and varied. They include geographic isolation, lack of transportation, language and cultural differences, economic disparity, and educational deficits that create challenges for rural health care providers. Lower population density in rural areas limits effective market demand for structurally safe housing, fresh food, health care, and jobs offering group health insurance (Glasgow, Johnson, Wright Morton 2004). According to Schur and Franco (1999), as late as 1996, more than three times the number of physician-specialists per 100,000 residents practiced in metro versus nonmetro counties. Studies by Glasgow (2000) and Burkhardt (2000) document that nonmetro residents travel farther than their metro counterparts to reach sources of medical care. In addition, rural populations face the extra challenge of arranging these trips in the face of largely absent public transportation systems. Research by Aday, Quill, and Reyes-Gibbs (2001) reported that in 1996 19.2 percent of individuals 64 years of age and younger living in nonmetro counties in the United States had no health insurance compared to 15.3 percent of individuals in the same age group in metro counties. In addition, nonmetro residents are more likely to be covered by Medicaid or other public assistance and less likely to be covered by private insurance plans (Hummer et al. 2004). When combined, these variables represent formidable obstacles for improving the health of rural residents. One way to address these complex issues is to provide culturally and socially appropriate services to the people where they live and work. Community Health Mapping Overview The CHM program provides health profiles of communities by examining health services, health education, and environmental health issues found within individual communities. It helps community members in consensus building and facilitates the formulation of an action plan by identifying key issues in community health. This empowers residents to take more responsibility for their own health and decreases the duplication of services and resources. The project blends visioning and planning techniques to bring key stakeholders and concerned citizens together to work towards an overall healthy community and collectively plan for action. The program includes a visioning and planning model developed through the Illinois Institute for Rural Affairs (IIRA) Community and Economic Development Program. The MAPPING (Management and Planning Programs Involving Non-metropolitan Groups) the Future of Your Community is a strategic visioning and planning process whereby local residents of rural communities create a long-term vision for the economic development of their community and a plan of action for obtaining it. Developed in 1991, the MAPPING program seeks to improve the economic vitality of rural Illinois communities. The MAPPING process enhances local decisionmaking by providing accurate information, effective forums for public dialogue and problem solving, and knowledge of innovative practices that are consistent with a community’s vision for growth and change. Community Health Mapping - 43 - Health Care Services Healthy People Health Education Environmental Health Community Health Where are we now? Goals How do we get there? Vision Where do we want to be? Figure 1: Community Health Mapping Community Health Mapping (CHM) applies the MAPPING techniques to health care development and is a tool that local leaders and citizens can use to create a shared vision of the community’s future and generate momentum to put the plan into action. The process consists of an assessment process and four visioning sessions followed by a network of logistical support and technical assistance. The assessment includes building community profiles, which examine health serves, health education, and environmental quality. The visioning sessions are organized around a central theme: “Where are we now?” “Where do we want to be?” “How do we get there?” and “Making it Happen and Keeping it Going!” During the course of this process, the participants (1) identify high-priority goals for a healthy community, (2) develop a feasible action plan, and (3) organize to begin to tackle the implementation. The outcomes from the project are measurable and include (1) number of health care services maintained, expanded, and/or developed in rural areas, (2) number of health education opportunities created or expanded to address the health issues for rural residents, (3) number of environmental programs or projects developed or completed to address complex environmental issues, (4) number of technical assistance encounters offered by IIRA through our state partners, (5) number of health assessments conducted for rural communities, and (6) number of communities actively engaged in projects developed through their visioning and planning process. - 44 - Public Health Practice in Illinois The CHM program began as a pilot study in 1995 and developed into a full-fledged program in 2000. Since its inception 12 communities have completed the process and the IIRA is working with an additional 2 communities to prepare them for projects in the coming year. CHM communities tend to be geographically clustered in the west central portion of the state, due to a lack of public health programs in the region. County Hancock Hamilton Washington Vermilion Pike Henderson Warren LaSalle McDonough Henry Greene Mercer Ogle Mapping Year 2001 2001 2001 2002 2003 2003 1995 2005 2004 & 2005 (2 communities) 2004 2005 2005 2006 Follow Up Survey in 2005 Update in 2005 Update in 2004 One Community completed an extended Community MAPPING Table 1: CHM Communities As a program CHM has established a broad network of contacts which are frequently called upon to assist CHM communities. Current partners include: • Illinois Department of Public Health-Center for Rural Health • Illinois Critical Access Hospital Network • RMED • AHEC • National Center for Rural Health Professionals • SIU School of Medicine • Illinois Rural Health Association • USDA-Rural Development • Department of Community Health and Health Services Management, Western Illinois University • Sociology/Anthropology Department, Western Illinois University The Health Resource team continues to look for future partners and develop health programming to meet the needs of rural areas. These partnerships provide valuable insight into the issues facing rural areas, as well as availability of programs, community support efforts, data, and other valuable resources. Community Health Mapping - 45 - Collaborative in Nature The Community Health Mapping program is a unique opportunity for those other than health care providers to discuss the future of health care in their community. The process provides a neutral platform for collaboration among economic developers, health professionals, local leaders, and concerned citizens to address health care trends, envision a healthier future, and determine a plan of action to achieve it. The program design is flexible and allows us to work with communities on a local or county level. The program bridges the gap between health care and the economic leaders. As regions identify similar issues, community groups are linked with others throughout their region and other communities throughout the state. The communities involved in the CHM program must be prepared to plan for the future of their health. Communities are expected to raise sponsorship fees, based on population, to participate in the process. The sponsorship provides ownership and buy-in to the program. Our experience shows that communities are more fully engaged in the process if they are required to network and discuss the project with others and have the drive to request financial support for the process. Communities work together to identify potential partners, which in turn provides a network of rural health providers, provides financial stability for programs, and ensures a healthier future for the communities involved. The population of rural communities engaged in the CHM process ranges from 1,500-8,500 people. On several occasions CHM has been conducted on a county-wide level, thereby involving a broader audience. The typical number of core committee members depends in large part upon the number of objectives a community has identified. For example, a community that pinpoints two goals, i.e., (1) reducing the mortality and morbidity rates of area residents due to cardiovascular disease, and (2) becoming an elder-friendly community would have four core committee members. Each objective has one or two people serving in the leadership role. Attendance at open meetings usually ranges between 20-35 people, depending on the amount of buy-in people in the community feel they have. Strong leadership is integral to the success of CHM. If you do not have the right people at the table the community will not participate to the extent necessary for a successful outcome. The logistics of the CHM process are complex and therefore require a great deal of dedication from the community. Figure 2 provides a schema of the CHM process in greater detail. Currently the CHM employs one fulltime staff member, one graduate student assistant, and one undergraduate student assistant to administer the program. While the contact hours during the 16 week visions process are limited to four CHM visioning meetings, which last four hours each, the program requires a great deal of preparation time, often exceeding 300 hours depending on the readiness of the community before reaching this stage. - 46 - Public Health Practice in Illinois Community Health Mapping Strategy Working with Community Partners Networking Town Hall meeting upon completion of CHM program CHM Meeting 4 Working with Heterogeneous Rural Communities Assessment Workshop CHM Meeting 1 CHM Meeting 2 CHM Meeting 3 Independent CHM Meeting Process Reports Technical Assistance Timeline: 4-9 months Figure 2: CHM Process Healthy Communities Table 2 highlights some of the positive outcomes experienced by communities that participated in the Community Health Mapping program. Lessons Learned In sum, the Community Health Mapping program empowers communities by helping them identify their health care concerns, set goals for attaining a healthier lifestyle, and establish a road map to reach these goals. The greatest challenges facing communities in achieving their goals are threefold: (1) engaging established and respected community leaders in the process, (2) integrating new community members into the CHM process, and (3) identifying a local contact person who is truly engaged in the process. When the community is able to identify leadership qualities at these three levels the process can be one in which all community members feel free to voice their concerns and opinions and individuals feel free to participate in the process. Ultimately, this form of collaborative decision-making empowers rural populations, increases their social networks, and informs them about the power of being socially, politically, and economically engaged in their communities’ futures. Community Health Mapping - 47 - County Hamilton Goal • Developing an elderfriendly community Hamilton • Provide elderly health programming Hamilton • Provide farm safety programs for the youth Actions Taken • Completed background work for Assisted Living Facility • Conducted feasibility with funds from the Illinois Delta Network Project • Identified economic development as tool for improving overall health of community • Hired part time economic developer for community • Developed model for teen wellness programming • • • • • • • Number of Sessions Community Assessment 4 CHM meetings 1 independent CHM meeting 1 Town Hall meeting Community Assessment 4 CHM meetings 1 independent CHM meeting • 1 Town Hall meeting • • • • • • • • Community Assessment 4 CHM meetings 1 independent CHM meeting 1 Town Hall meeting Community Assessment 4 CHM meetings 1 independent CHM meeting 1 Town Hall meeting Hancock • Increase awareness of health care services Washington • Reduce mortality & morbidity rates due to cardiovascular disease • Completed resource directory of health care services & support servicesavailable CD-ROM format • Networked with health care providers in are to make them aware of communities concerns • Collaboration of health department & hospital to generate heart healthy programs for women & children • Pursuing Assisted Living Facility • • • • • • • • • • • • Washington • Become elderly friendly community Henderson • Increase economic development to improve community health • Hired part-time economic developer Community Assessment 4 CHM meetings 1 independent CHM meeting 1 Town Hall meeting Community Assessment 4 CHM meetings 1 independent CHM meeting 1 Town Hall meeting Community Assessment 4 CHM meetings 1 independent CHM meeting 1 Town Hall meeting Table 2: Positive Outcomes - 48 - Public Health Practice in Illinois Bibliography Aday, L., B. Quill, and C. Reyes-Gibby. (2001) Equity in rural health and health care. In Handbook of Rural Health. Edited by S. Loue and B. Quill, 45-72. New York: Kluwer Academic/Plenum Publishers. Burkhardt, J. (2000) Limitation of mass transportation and individual vehicle systems for older persons. In Mobility and Transportation in the Elderly, edited by W. Schaie and M. Pietrucha, 97-123. New York: Springer. Carlson, J., M. Lassey, and W. Lassey. (1981) Rural Society and the Environment in America, 112-141. New York: McGraw-Hill. Eberhardt, M., D. Ingram, D. Makuc, E. Pamuk, V. Fried, S. Harper, C. Schoenborn, and H. Xia. (2001) Health, United States, 2001 with Urban and Rural Chartbook. Electronic Document: www.cdc.gov/nchs. (Accessed November 12, 2005) Glasgow, N. (2000) Older Americans’ patterns of driving and using other transportation. Rural America. 15(3):26-31. Glasgow, N., N. Johnson, and L. Wright Morton. (2004) Introduction. In Critical Issues in Rural Health. Edited by N. Glasgow, L. Wright Morton, and N. Johnson. 3-14. Ames, Iowa: Blackwell. Hummer, R., J. Pacewicz, S-C. Wang, and C. Collins. (2004) Health Insurance Coverage in Nonmetropolitan America. In Critical Issues in Rural Health. Edited by N. Glasgow, L. Wright Morton, and N. Johnson. 197-210. Ames, Iowa: Blackwell. Rautianen, R. and S. Reynolds. (2002) Mortality and morbidity in agriculture in the United States. In Journal of Agricultural Safety and Health 8(3): 259-76. Schulman, M. and D. Slesinger. (2004) Health Hazards of Rural Extractive Industries and Occupations. In Critical Issues in Rural Health. Edited by N. Glasgow, L. Wright Morton, and N. Johnson. 49-60. Ames, Iowa: Blackwell. Schur, C. and S. Franco. (1999) Access to health care. In Rural Health in the United States. Edited by T. Ricketts III. 25-37. New York: Oxford University Press. Effective Chronic Disease Translation: A Regional Diabetes Coalition Paul K. Burkholder, MD Assistant Professor of Medicine Department of Medicine University of Illinois College of Medicine at Rockford Joella D. Warner, RN, MAT, CDE Assistant Professor of Medicine/Nurse Educator The National Center for Rural Health Professions Department of Medicine University of Illinois College of Medicine at Rockford For more information, contact: Paul K. Burkholder, MD, University of Illinois College of Medicine at Rockford, 1601 Parkview Avenue, Rockford, IL 61107; Phone: 815-395-5727; E-mail: pburkhol@uic.edu The Northern Illinois Diabetes Coalition (NIDC), an apolitical, not-for-profit organization, provides Northwest Illinois a means for translating clinically and research-derived information about diabetes at multiple levels: personal, community, programmatic, and professional/care delivery. Fifteen largely rural counties constitute the region defined for program development. Rockford is the largest city in this area. Addressing population health and using the community health information approach, NIDC views its target audience as individuals at risk for diabetes, those with diabetes and their families, community organizations, and the community at large. Programs and sustainable tools being developed by NIDC facilitate improving organization of primary, secondary, and tertiary diabetes preventive health care delivery. Development stages include transformations from the formative urban design into a more ubiquitous model with a range of applications appropriate for rural locales. Additionally, this review will describe the evolution from, at present, a largely professionally driven coalition to ultimately an organization that will encompass community representation and ownership. T he Northern Illinois Diabetes Coalition, an apolitical regional chronic disease community action model, represents a group of diabetes “champions” from Rockford and the surrounding area. This paper will highlight organizational and program elements and their evolutionary processes that have proved effective and could be transferred to other communities or coalitions. NIDC follows the principle that local/regional design and ownership of a chronic disease coalition provides an advantage for development and sustainability. In building community acceptance and participation, coalitions must model their initiatives to be adaptable within their regional milieu, whether rural or urban. - 50 - Public Health Practice in Illinois BACKGROUND The Rockford Health Council (RHC), founded by hospitals, health departments, community organizations, and industry in Boone, Ogle, and Winnebago Counties was reorganized in 1998 and subsequently conducted a “Healthy Community Survey”. The report of survey results included diabetes data that echoed national statistics. The prevalence of diabetes and the resulting high utilization of health care services have significant adverse impact on health status and cost of health care in the region. After the survey was evaluated, the RHC defined 16 “priorities” that needed to be addressed. The subsequent action plan defined appropriate leadership and organizations that would sponsor, support, and provide structure for each priority. The University of Illinois, College of Medicine at Rockford (UICOM-R) provides, jointly with the RHC, sponsorship for NIDC. Concurrent with these RHC and UICOM-R developments were the ongoing diverse diabetesrelated activities of (a) local and regional health departments, (b) intensely competitive hospitals, and (c) both private practice-based and community health clinics. Entities representing each of these groups present to their patient/client base and their service area varied levels of traditional diabetes education and episodic community diabetes forums. However, the element missing from the existing milieu was that of coordinated initiatives for individuals with diabetes, those at risk for diabetes and their families, as well as coordinated planning for these activities throughout the Northern Illinois region. In the background of these multiple community-based initiatives were the limited fund-raising and information distribution activities of two national organizations: the American Diabetes Association and the Juvenile Diabetes Research Foundation, having no significant impact upon diabetes program development in Northwest Illinois. METHODS (Overview of NIDC Development) Structure The Northern Illinois Diabetes Coalition was originally organized by contacting people in organizations and individuals from Winnebago County who had a particular interest in diabetes education and care. At the formative meeting, held in 1999, community diabetes care needs were discussed. Participants agreed that an impartial approach to diabetes care was needed, and several volunteered to become leaders in establishing a coalition. This group, called the pro tem executive committee, met from July through December to write a mission statement (Figure 1), develop by-laws, and define committee structure. The initial funding for NIDC came from UICOM-R providing space and amenities for meetings and leadership from faculty. Other groups and/or individuals volunteered their time. Effective Chronic Disease Translation Figure 1: Mission Statement of the NIDC The mission of the Northern Illinois Diabetes Coalition is to reduce morbidity and mortality and enhance the quality of life for people with diabetes. The NIDC will accomplish this mission in order: • To raise awareness of patients, health professionals, and the public that diabetes is a serious disease, • To promote the appropriate diagnosis and management of diabetes by health professionals, • To encourage diabetes patients, regardless of income, race, gender, creed, language or any disability, to enter into continuing care by facilitating access to care, • To encourage a partnership among patients and health care providers through modern treatment and education programs, and • To encourage community partnership and collaboration among educational institutions, employers, providers, payers, and other interested parties to support diabetes research and training of health care professionals. - 51 - Initially, chairpersons were secured for four committees: Community Care, Education (both community and professional), Translating Clinical Research into Practice, and Managed Care and Data Collection. The challenge was to establish working committees to accomplish the goals of the coalition. A UICOM-R faculty member served as a resource for development of each committee. Some of the initial goals were to: create a survey to find out how people with diabetes viewed the disease, the care they received and what they wanted to know more about; provide an education program for health professionals to update their knowledge of diabetes care; create a guideline for providers to use for diabetes care (focusing on the American Diabetes Association Clinical Recommendations); and to create a regional registry of persons with diabetes. Figure 2: NIDC Service Area - 52 - Public Health Practice in Illinois Since the inception of NIDC, committees have grown, changed chairpersons and continued to meet regularly to achieve the mission of the Coalition. In the fall of 2001, the Center for Rural Health Professions at UICOM-R, was designated as the Northern Illinois Area Health Education Center (NIAHEC) for 15 counties. At that point in time, leadership in the NIDC decided to also create liaisons with individuals and health professionals in those counties, most of which are rural, for improvement of diabetes care (Figure 2). Initiatives are being designed to cultivate lasting relationships with and a sense of belonging to NIDC within these counties. An initial endeavor was the identification of a contact person in each county who will be the correspondent for the Community Care Committee’s bilingual (English/Spanish) support group information sheet and NIDC Notes. A subsequent step will be the development of a diabetes-related needs assessment for individuals and organizations within each county in order to improve communication and program development. Additionally, NIDC has held two community programs in Stephenson County and one in Boone County. NIDC members in DeKalb and Stephenson Counties are active in several committees. Furthermore, an original DeKalb County-wide household diabetes survey was adapted by NIDC to form the second NIDC diabetes survey. Subsequent committee changes/additions to the executive committee include combining the Education and Translating Clinical Research into Practice Committees, and developing a Marketing and Public Relations Committee, a Development Committee, and a Volunteer Committee. The Executive Committee meetings are open for individuals, groups, and /or organizations to visit, explore, and decide whether to participate with NIDC. As a result, NIDC committees are culturally and ethnically integrated. Membership in NIDC remains open to any individuals facing the challenges that diabetes presents either personally or in the community. Membership is free of charge and includes a subscription to the quarterly NIDC Notes. Definition of membership will continue to be discussed with respect to membership activities, obligations, and possible financial support through membership dues. To-date NIDC has 1200 members. NIDC “Products and Tools” The first two years were a time for planning and organizational steps marked by a paucity of funding to launch proposed projects. With the addition of a Development Committee, a successful fund-raiser along with subsequent funding resources enable individual committees to launch various initiatives. Table 1 summarizes accomplishments to date. Effective Chronic Disease Translation - 53 - Community Care Committee: o Edits and distributes a quarterly bilingual (English/Spanish) flyer announcing regional diabetes support group activities: this is included in the NIDC newsletter with future distribution via e-mail and NIDC website o Conducted the initial community survey regarding satisfaction that individuals with diabetes have in health care delivered to them o Is developing a regional diabetes speakers’ bureau Education Committee: o Designs and hosts a wide variety of educational events for patients, the public, and health professionals; these events are beginning to be hosted in rural counties outside of Winnebago County o Developed the NIDC educational poster display that is used at health fairs and other public events o Focuses professional education on evidence-based diabetes practice and effective care delivery paradigms o Collaborates with the Annual UICOM-R Diabetes Conference planning and the UICOM-R Department of Medicine CME events Managed Care and Data Collection Committee: o Conducting current region-wide assessment of diabetes care levels via a bilingual (English/Spanish) diabetes survey; results will assist NIDC educational and programmatic initiatives o Launching a long range development program to establish a regional diabetes registry Development Committee: o Conducted successful fund-raising events with financial support coming from health care and other corporate entities as well as individual gifts o Developed a diabetes awareness enhancing video with companion PSAs that premiered in 2003 (this was a collaboration with the Marketing and Public Relations Committee) o Spearheaded a successful effort to make NIDC a State of Illinois not-for-profit organization with its Federal 501c3 designation Volunteer Committee: o Recruits and educates a pool of individuals who will represent diabetes causes and NIDC at regional health fairs and other public events Marketing and Public Relations Committee: o Provides news releases and arranges television interviews and programs o Launched the website, NorthernIDC.org o Publishes “NIDC Notes”, the quarterly newsletter o Developed and distributed the NIDC specific diabetes advocacy ribbons o Develops and produces a variety of print and other products for use in enhancing public awareness regarding NIDC and the array of diabetes issues Table 1: Summary of the accomplishments to date of the various NIDC committees RESULTS Community Care Committee Community Survey, 2000 In an attempt to determine the needs of people with diabetes in the community, a bilingual (English/Spanish) survey was developed that asked questions about diabetes knowledge, perceptions of diabetes care, and the information that people with diabetes would like. The - 54 - Public Health Practice in Illinois survey was administered at two health fairs to a total of 240 people. Eighty percent (80%) of the respondents stated that they had diabetes and fifty-seven percent (57%) indicated they had type 2 diabetes. Responses to questions indicating attitudes, beliefs and observations about diabetes were: (percent = “strongly agree” or “agree”). • It is hard to know what to eat or drink. 24% • It is easy to become depressed. 67% • MD needs to spend more time. 73% • Diabetes is well managed. 23% • Insurance covers costs of diabetes care. 24% • MD performs foot exam at each visit. 34%. The results of the survey were used by NIDC to provide professional and community educational events, create a poster display to use at health fairs and other venues, choose educational materials for distribution, and develop a second survey that included a consent form and request for information card so participants can be entered into the regional diabetes registry. Examples of professional and community events have been: • “Team Approach to Enhancing Patient Management in the Primary Care Office” – a CME/CEU-based interdisciplinary Problem Based Learning event with 61 participants. • “Diabetes Neuropathy – Prevention and Care of Complications” – two days of professional and community presentations. One of the professional sessions provided live televised interviews and examinations of individuals with diabetic neuropathy and active foot wounds by an expert and also provided a tutorial for 44 professionals that allowed hands-on practice of the complete foot examination. • Development and use of the display poster with the theme “The Sky’s the Limit” that promotes guidelines regarding diabetes care. Collaborative Programs NIDC is increasingly moving toward collaborative endeavors. This process is in symmetry with the adopted inclusionary, apolitical stance. The process requires time, dialogue, and definition of each group’s goals, approaches, and resources. NIDC collaborates with other Rockford Health Council (RHC) initiatives and multiple community organizations including faith-based groups, minority/ethnic groups, community health clinics, hospitals, health professional groups, and educational institutions. An example of early collaboration was in preparation of a Robert Wood Johnson Foundation grant application, based on the implementation of the Chronic Disease SelfManagement Program (1). Although this effort did not yield grant support, it has led to the recognition of NIDC by these community groups and organizations. Another example is that of co-sponsoring the UICOM-R Annual Diabetes Conference with the Rock River Valley Dietetic Association and the Rock River Association of Diabetes Educators. NIDC also partnered with multiple organizations in an RHC-chaired application for a Steps to a Healthier US (STEPS) grant and a Minority Health Project grant. Currently, NIDC is addressing precursors to obesity Effective Chronic Disease Translation - 55 - and diabetes as they apply to student health. Three collaborative components of school-based initiatives that address kindergarten through college include: a) Becoming a member of an Elementary School Community Action Council (composed of nine community organizations), to launch a multiyear program that addresses the child, the family, and the community regarding issues of nutrition and exercise with the ultimate goal of screening the child at high risk for obesity, pre-diabetes, and related conditions. The elementary school is located in Rockford, Illinois. b) Designing a similar, more abbreviated version for middle and high school students and proposing collaboration with the school district in South Beloit, Illinois. c) Initiating collaboration with the Northern Illinois University Resources for Latinos (URL) addressing challenges Latino students face during their college and graduate work related to proper nutrition, exercise, and appropriate screening and care for those at high risk for diabetes and related conditions. The Rockford-based school project represents a truly “grassroots” endeavor within one ZIP Code of the community that includes an action plan for the school. Improving educational outcomes for the children and addressing health issues involving the children, families, and community are the major goals of the action plan. Through these collaborative relationships, NIDC has broadened its own view of diabetes and related initiatives so that the orientation is toward the prevention of type 2 diabetes, the metabolic syndrome, and associated environmental causative elements. The process included an initial survey, the “Millennium Neighborhood Survey” that addresses population health needs in the targeted Rockford school neighborhood. The population health needs are impacted by the major issues of safety, poverty, drug culture, and citizens’ feelings of disenfranchisement and alienation from the school and community. Preliminary results from this survey of 274 residents in a selected neighborhood within the targeted ZIP Code are: 26.3% of the adult respondents stated they have diabetes; 47.4% have family members with diabetes; 34% of the respondents are overweight; and 16-20% of their children are overweight. Strategic Planning In the formative stages of NIDC, the leadership of the Executive Committee (EC) conducted the planning. As the committees have matured, planning occurs at the committee level with final review by the EC. As a result, each committee formulated a 5-year strategic plan that became NIDC’s strategic plan. The strategic plan contains appropriate budget projections and addresses the diabetes-related goals of Healthy People 2010(2). Some of the desired benefits from this planning approach are: o Developing sustainability of the organization and its projects o Defining multi-tiered approaches to community-based interventions o Re-engineering membership to include more community organizations and enhanced opportunities for individual participation o Regionalizing growth by planning the structure for effective program and project development in 15 counties. - 56 - Public Health Practice in Illinois DISCUSSION According to Thompson and Kinne (3) from a discussion on social change theory, subsystems of the community that consist primarily of organizations and individuals working toward a common goal can have an effect on changing the way communities approach a problem. The NIDC can be viewed as a community subsystem that has brought together organizations and individuals that work toward a common goal, that of primary prevention, detection, and improved care of diabetes. Through integration and inclusion, NIDC can be more successful in the more traditional roles of providing education, program planning, and grant writing. In the schematic of the community as a system portrayed by Thompson and Kinne, NIDC fulfills roles at the inter-relationship and the subsystem levels, while simultaneously enhancing collaboration between the multiple entities at the subsystem level. In Healthy People 2010 (4), Objective 7-10 focuses on the need for comprehensive health promotion/community health improvement activities. The document cites a report that points out that the majority of such activities in urban areas have not defined a specific model for program planning and implementation that includes community members. NIDC was founded with the aim of applying population health approaches to diabetes, a chronic illness that is a major health problem locally, nationally, and worldwide. Currently, traditionally formatted diabetes care/education delivered by providers/educators in clinics, hospitals, and health departments remain targeted at the individual and family and are directed at secondary and tertiary preventive treatments. These discrete intervention sites are seldom merged into broader consortiums that address important primary and secondary prevention needs in the community at large. The chronic care model provides a guide to integrate and coordinate functions that maintain the broad overview of population health. Integral to this model is the integrating and coordinating function of a community or region-wide organization that maintains the broad view of population health.(5) NIDC maintains the vision and mission of providing some or as much as possible of these functions. Finally, the limitations/challenges faced by this all-volunteer not-for-profit organization remain those faced by many similar organizations: ongoing funding needs and nurturing participation and collaboration of citizen members and health professionals. The evolution of the NIDC, as it follows its quest for improving population diabetes-related health, will be in moving from an infrastructure of committees and conventional programbuilding tools to that of defining comprehensive, effective community-based interventions that are supported by ongoing program evaluation. In doing so and to ensure success, NIDC finds that it must increasingly collaborate with community organizations. One of the lessons learned is to use the population health approach to finding community solutions. Building trust with other organizations in the community is mandatory as a healthoriented organization addresses its goal of completing a more focused program in primary prevention and screening for a specific array of health problems. Effective Chronic Disease Translation - 57 - CONCLUSIONS The benefits of collaborating in this regional chronic disease endeavor multiply and enrich community contacts, gain acceptance, and develop community ownership of the organization. An apolitical policy, free from limitations and self-interests seen in many community organizations, is exceedingly important to allow unfettered participation by many community representatives. This in turn leads to collaboration, both by individuals and groups, in designing effective program initiatives. GRANT SUPPORT The Millennium Neighborhood Survey was supported by a grant from the State Nutrition and Physical Activity Program of the Illinois Department of Public Health. REFERENCES 1. Lorig, KR, et al. (1999) Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A Randomized Trial. Medical Care. 37(1): 5-14 2. Diabetes. Healthy People 2010 (Conference Edition, in Two Volumes). U.S. Department of Health and Human Services. Washington, DC. Chapter 5, 1-38. 3. Thompson, B., & Kinne, S. (1990) Social change theory: Applications to community health. In Bracht, N., ed. Health Promotion at the Community Level, pp. 45-65. Thousand Oaks, California: Sage Publications. 4. Educational and Community-Based Programs. Healthy People 2010 (Conference Edition, in Two Volumes). U.S. Department of Health and Human Services. Washington, DC: January 2000. Chapter 7, pp. 1-31. 5. Wagner, E H. (1998). Chronic disease management: What will it take to improve care for chronic illness. Effective Clinical Practice; 1(1): 2-4 Addressing Rural Health Disparities in Illinois: Oral Health Karen E. Peters Illinois Prevention Research Center, University of Illinois at Chicago William W. Baldyga Illinois Prevention Research Center, University of Illinois at Chicago Lewis N. Lampiris Division of Oral Health, Illinois Department of Public Health Julie A. Jensen Division of Oral Health, Illinois Department of Public Health Anne L. Koerber College of Dentistry, University of Illinois at Chicago Linda M. Kaste College of Dentistry, University of Illinois at Chicago Susan R. Levy Illinois Prevention Research Center, University of Illinois at Chicago This article is dedicated in memory of Dr. Herbert M. Hazelkorn, DDS PHD, a "character" full of charm, intellect, generosity and wit and a "voice" for progressive thought and action in oral health, public health and dentistry. ublication of the Surgeon General's Report in 2000, "Oral Health in America," provided the United States with a Call to Action that demands improvement in oral health for the Nation. The Report also mobilized state and local activity concerning oral health. The Surgeon General's Report identified a number of significant oral health issues including: • • • • • Oral health affects health and well being throughout the life cycle Dental caries and periodontal diseases, the most common of oral diseases, can be prevented through safe and effective preventive measures Lifestyle factors such as poor dietary choices, tobacco and excessive alcohol use affect oral and craniofacial health as well as general health The mouth reflects general health and well being There are profound and consequential oral health disparities within the US population P The Surgeon General's Report issued a call for creating effective oral health infrastructure that addresses the oral health needs of all Americans and integrates oral health effectively into overall health. In response to the Surgeon General's “Call for Action”, the State of Illinois has engaged in a series of related activities to formulate a comprehensive vision and plan for oral health in - 60 - Public Health Practice in Illinois Illinois. This paper provides an overview of the current status of oral health in the state with a particular emphasis on rural Illinois and describes current activity to meet Illinois’ oral health needs. A companion document to the Surgeon Generals Report by the National Rural Health Association entitled "Oral Health in America: A Rural Perspective" highlights that nationwide, those who live in rural and frontier areas are less likely to have good oral health (NRHA, 2001). Barriers to good oral health in rural areas can be classified into two major groups; provider issues and consumer issues. Provider issues include a lack of dentists practicing in rural areas; limitations in provider acceptance of Medicaid patients due to low Medicaid reimbursement; optional coverage for adult dental services under Medicaid; lack of adequate training among dentists for the special oral health needs of rural residents. Consumer related issues include lack of or limited dental insurance; transportation and scheduling difficulties; cultural belief systems and racial, ethnic and language barriers. Oral Health Disparity in Illinois With regard to the supply and distribution of dentists in the state of Illinois, there are only 21 counties that are not considered dental health professional shortage areas as seen in Figure 1 below. This translates into unmet oral health care needs. More than one third of Illinois adults do not have any form of dental insurance and 14% needed to see a dentist during the past year but could not afford to go due to cost. It is interesting to note that 72% of adults in Illinois did visit a dentist within the last year and 69% had their teeth cleaned by a dentist or dental hygienist (Illinois Department of Public Health, Center for Health Statistics, 2003) In a recently released report (2003) by the Illinois Department of Public Health, Oral Health: A Link to General Health, several disparities in oral health are noted. With regard to children's oral health, a survey, Project Smile, conducted in the 1993-1994 school year in grades one, two and eight indicates that children in Illinois continue to suffer from preventable oral diseases. For example, • • • • • • • • 54% of children had evidence of dental decay on either baby or permanent teeth 38% of 6-8 year olds had untreated dental decay 30% of 15 year olds had untreated dental decay 78% of white children were decay free; 76% of African American children were decay free and 67% of Hispanic children were decay free 13% of children had at least one dental sealant on permanent teeth 55% were in need of dental sealants 18% of white children has sealants on permanent teeth; 4% of Hispanic children had sealants and 3% of African American children had sealants 42% of children had gingivitis (49% of African American children; 46% in Hispanic children and 39% in white children) Oral Health - 61 - Figure 1: Federally Designated Dental Health Professional Shortage Areas in Illinois - 62 - Public Health Practice in Illinois With regard to access to oral health care for children, it was found that only 33% of children enrolled in Medicaid or SCHIP utilized oral health care during the year and only 34% of active general and pediatric dentists were enrolled as Medicaid providers. In Illinois, only 17 of the 102 counties have a pediatric dentist as depicted in Figure 2. Figure 2: Illinois counties with at least one pediatric dentist Source: University of Illinois – Chicago, Center for Health Workforce Studies, 2001 Oral Health - 63 - Oral cancer is yet another area where health disparity is evident in Illinois. Illinois oral cancer statistics indicate that less than 40% of oral cancer cases are diagnosed at an early stage. African American males have the highest number of new oral cancer cases being diagnosed (Illinois Department of Public Health, Illinois State Cancer Registry, 2003). Figure 3 shows Illinois counties with their corresponding percent of late stage cancer diagnosis. Oral Cancer Incidence Illinois 1986 - 1998 Percent Late Stage Diagnosis Jo Daviess Stephenson W innebago Boone McHenry Lake Carroll O gle DeKalb Kane DuPage Cook W hiteside Lee Kendall W ill Rock Island Henry Mercer Stark Bureau La Salle Putnam Kankakee Marshall Grundy Knox Henderson W arren Peoria W oodford Ford Livingston Iroquois Tazew ell Hancock McDonough Fulton McLean Mason Schuyler Adam s Brow n Cass Menard Logan De W itt Piatt Cham paign Verm ilion Macon Morgan Sangamon Christian Moultrie Coles Shelby Greene Macoupin Calhoun Montgom ery Cumberland Clark Douglas Edgar Pike Scott Jersey Fayette Bond Madison Effingham Jasper Crawford Clay Marion Clinton St. Clair W ashington Monroe Jefferson W ayne Richland Lawrence Percent Late Stage Incidence by County 50 to 74 38 to 50 11.1 to 38 Edwards abash W Perry Randolph Franklin Ham ilton W hite Jackson W illiam son Saline Gallatin Union Hardin Johnson Pope Pulaski Alexander Massac Figure 3: Oral cancer incidence by county – late stage diagnosis by percentage (1985-1998) Source: Illinois Department of Public Health, Division of Epidemiologic Studies, 2002 - 64 - Public Health Practice in Illinois Rural Oral Health Disparities Information available from the 2002 Illinois County Behavioral Risk Factor Surveillance System (ICBRFSS) provides an even more detailed indication of the disparities in oral health, especially those for rural Illinois residents. Table 1: ICBRFSS Oral Health Indicators by Illinois County Strata compared to the State and US (2002) Rural Urban Collar Suburban Chicago Illinois US Counties Counties Counties Cook (2002) Loss of 6+ Teeth due to 12.7% 11.4% 7.9% 8.9% 12.6% 10.4% 17.6% decay/gum disease Dental Visit within Past 62.1% 76.7% 72.9% 77.0% 70.5% 72.2%% 69.2% Year Had teeth cleaned within 55.1% 72.0% 71.7% 79.1% 69.1% 69.8%% 69.2% Past year Have Dental Insurance 53.9% 69.6% 68.5% 63.8% 57.9% 63.1%% N/A As indicated by Table 1, rural counties in Illinois have slightly higher rates of loss of 6 or more teeth due to decay/gum disease compared with other county strata in the state, but the overall US rate is higher (12.7% vs. 17.6%). Rural Illinois resident have much lower rates of dental visits within the past year compared to all other strata, the state and the nation. Similarly, a lower rate for having teeth cleaned within the past year is also evident among rural residents compared to all other groupings. The lower rates of oral health related services might be due, in part, to the lower rates of dental insurance reported among rural residents compared to others. Each of these indicators suggests that rural residents suffer a disproportionate burden of oral health care need in the state of Illinois. Addressing Oral Health Disparity in Illinois Illinois continues to address the issue of oral health disparity through a variety of strategic planning and coalition building strategies. With the input of a variety of stakeholders throughout the state, the Illinois Oral Health Plan has been developed and is currently being implemented. The Plan represents a comprehensive vision that has been adopted by the oral health community in Illinois. There are five policy goals to the plan as well as Illinois-specific priorities as indicated in Table 2 below. Table 2: Five Policy Goals and Illinois Specific Priorities Goal Change perceptions regarding oral health and disease so that oral health becomes an accepted component of general health Build an effective infrastructure that meets the oral health needs of all Priorities Educate the public, health professionals and decision-makers about the relationship between oral health and systemic health Maximize the use of the entire health care and dental heath workforce - to educate the public on the value and importance of oral health Increase the representation of African-Americans and Hispanics in Illinois dental and dental hygiene schools Oral Health Illinoisians and integrates oral health effectively into overall health Increase the number and types of community-based experiences that benefit both communities and students of dentistry and dental hygiene - 65 - Improve outreach to involve dentists and dental hygienists in private practice in community-based efforts to improve oral health and access to care Establish a uniform system for assessing oral health workforce capacity as a component of an Illinois oral health surveillance system Assure capacity of schools of dentistry and dental hygiene to recruit and retain faculty and to provide state-of-the-art teaching and research opportunities Expand the scope of Medicaid- covered oral health services to include preventive services for adults Increase the start-up and maintenance funding resources available for public dental clinics to address the unmet oral health needs of the Medicaid population, the uninsured and underinsured Expand funding for IDPH's school based dental sealant program to allow dissemination of the program throughout Illinois Identify funding streams for a statewide community-based education and awareness program, pilot projects in care coordination to improve access to services, and early childhood caries prevention programs Develop an Illinois loan repayment program for dentists and hygienists who agree to practice in dental underserved areas and to treat underserved populations Expand the dental workforce in rural areas Accelerate the building of the science and evidence base and apply science effectively to improve oral health Develop an oral health surveillance system or a common set of data that can be used to define the scope of oral health needs and access to oral health services, to monitor community water fluoridation status and to measure the utilization of dental services by the entire population of Illinois Maximize the contribution and use of existing public health data to inform the science base necessary to improve oral health in Illinois Monitor the implementation and continued development of the Illinois Oral Heath Plan Establish a formal mechanism for leaders in dental education to convene on a routine basis and discuss strategies, synergies and opportunities Support the IFLOSS Coalition as a working public/private partnership focused on oral heath improvement for all residents of Illinois Assure the active participation of the oral health community in statewide health improvement organizations Include representatives from key stakeholder groups and from populations disproportionately affected by oral health problems in the planning and implementation of ideas in the oral health plan, as well as other communities that monitor and provide oral health of Illinois residents Remove known barriers between people and oral health services Use public-private partnerships to improve the oral health of those who suffer disproportionately from oral diseases - 66 - Public Health Practice in Illinois The first Illinois Oral Health Plan was adopted on January 22, 2002 and is on file with the Division of Oral Health of the Illinois Department of Public Health. The Plan is intended to serve as a guidepost for reducing disparity in oral health and thereby improving the oral health of all of the citizens of Illinois. At the present time, planning for the second Illinois Oral Health Plan is taking place and the second five year state Oral Health Plan will be released in 2007. A major contributor to the state’s oral health planning efforts is the IFLOSS Coalition which was formed as a private-public partnership in 1998. The IFLOSS Coalition was created to assist the state in its efforts to reach un-insured and under-insured individuals through community-based outreach and education efforts and to expand the state’s safety net clinics. The Coalition was established through community collaborative partnerships which are designed to reduce the burden of oral disease throughout the state (www.IFLOSS.org). With regard to rural oral health concerns, the Oral Health Plan specifically highlights the need to address the dental health professional shortages in Illinois and calls specific attention to the issue of access to oral health services among those with inadequate or non-existent dental insurance. Conclusion The situation in Illinois mirrors that of the Nation with regard to oral health concerns. While Illinois performs slightly better when compared to the Nation as a whole, there are persistent oral health disparities for individuals who reside in rural areas of the state. Through the on-going, community level efforts of the IFLOSS coalition and the “Call to Action” outlined in the state’s Oral Health Plan, it is likely that these inequalities can be reduced. Oral Health - 67 - References IFLOSS Coalition (2002) Roadmap to the Future: Oral Health in Illinois - the Illinois Oral Health Plan and the Community Oral Health Infrastructure Development Project (www.IFLOSS.org) CDC (2001) Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries. MMWR/Recommendations and Reports; 50(RR-21), November 30. Illinois Department of Public Health, Illinois State Cancer Registry, Incidence Data January 2003 – Morality Data, Death Master File 1996-2000. American Journal of Preventive Medicine (2002) A report on evidence, findings and expert commentaries. Volume 23; Issue 1 Supplement 1. See www.thecommunityguide.org/oral for links to individual articles. Illinois Department of Public Health, The Oral Health Status of Children 1985-1996. Illinois Department of Public Health (2003) Oral Health: A Link to General Health. Available at http://www.idph.state.il.us/HealthWellness/oralhlth/BurdenDocument.pdf Illinois Department of Public Health, Center for Health Statistics. Illinois Behavioral Risk Factor Surveillance System, 2001.http://www.uic.edu/sph/irhwc/irha%20report%20gb%20final.pdf Byck, Gayle R. PhD., Cooksey, Judith M.D., M.P.H., and Surrey Walton PhD. Access to Oral Health Care for Medicaid Children in Illinois: A focus on Rural Illinois, Illinois Center for Health Workforce Studies, Chicago, IL February, 2001. The Mid-America Public Health Training Center subscription rates are for annual volumes. When you subscribe, you will receive an entire volume, consisting of four issues. Limited numbers of past volumes and single issues are also available. See http://www.uic.edu/sph/chs/php/PUBLICATIONS/ for listing of topics. Leadership in Public Health Public Health Practice in Illinois (formerly Illinois Morbidity and Mortality Review) $30.00 $30.00 $50.00 For Both, pay only ...... Make check or money order payable to: THE UNIVERSITY OF ILLINOIS Mail to: MAPHTC Subscriptions Center for Public Health Practice (M/C 923) UIC School of Public Health 1603 West Taylor Street Chicago, IL 60612 ___ Leadership in Public Health ___ Public Health Practice in Illinois (formerly Illinois Morbidity & Mortality Review) SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE SUBSCRIBE Subscriber Name & Degree: Title & Department: Agency: Mailing Address: City / State / Zip: Phone Number: E-Mail: Journal subscription may also be purchase online at http://maphtc.uic.edu/Public/ A Comprehensive Publication on Infectious Disease History in Illinois! From Yellow Fever to the AIDS Epidemic: A History of Infectious Disease in Illinois Ross Mullner, PhD, MPH (Forward by Bernard J. Turnock, MD, MPH) TABLE OF CONTENTS 1. Introduction 2. Yellow Fever 3. Smallpox 4. Diphtheria 5. Influenza 6. Malaria 7. Typhoid Fever 8. Tuberculosis 9. Poliomyelitis 10. Measles 11. Syphilis 12. AIDS 13. Conclusion Ross Mullner, PhD, MPH, is Associate Professor of Health Policy and Administration at the University of Illinois Chicago School of Public Health. Dr. Mullner is the author of over 100 publications in the areas of health services research, healthcare marketing, and the history of public health. He has written seven books including Deadly Glow: The Radium Dial Worker Tragedy, published by the American Public Health Association. From Yellow Fever to the AIDS Epidemic: A History of Infectious Diseases in Illinois is the exciting history of the rise and fall of the major infectious diseases in the state. This comprehensive monograph is over 200 pages in length and contains numerous graphs and maps plotted by the author, which are not available anywhere else. The work also contains many rare photographs and clippings from newspapers, magazines, and journals that illustrate the various types of public health interventions used in Illinois. _________________________________________________________ PLACE YOUR ORDERS NOW!!! To order your personal copy, fill out this portion and mail with payment to: Mid-America Public Health Training Center (MAPHTC), UIC, School of Public Health 1603 W. Taylor Street, M/C 923, Chicago, IL 60612 OR purchase it online at http://maphtc.uic.edu/Public/ Name: Agency: Address: Telephone: Publication: From Yellow Fever to the AIDS Epidemic Please make checks payable to the University of Illinois ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ __________________ Fax: ______________________ E-mail: ______________________ # of copies _______ Unit price $20.00 Total price ________ . Orientation Manual for Illinois Board of Health Members 2004 – 2005 Edition The Board of Health Manual is designed to orient local health board members and other officials to the world of public health in Illinois; provide local health board members with useful reference materials; give a greater understanding of important concerns and issues facing local boards of health; and increase the ability of board members to fulfill their responsibilities in an informed, insightful, and effective manner. The fourth edition of this Manual contains new and updated information about the structure of public health services in Illinois. New sections on Meeting Management, Health Information Portability and Accountability Act (HIPAA) and Emergency Preparedness have been added. This edition provides updated organizational charts of the Illinois Department of Public Health and the Illinois Department of Human Services to reflect recent changes in administration. Furthermore, a directory of local health departments in Illinois, a listing of NALBOH (National Association of Local Boards of Health) representatives and events are provided. It has been prepared by the Mid-America Public Health Training Center and the Center for Public Health Practice of the University of Illinois at Chicago School of Public Health. No. of Copies Board of Health Manual ________ Unit Price $25 Total Price _______ Name: _____________________________________________________________________ Agency: ____________________________________________________________________ Address: ____________________________________________________________________ City: ____________________________ State __________________ ZIP ______________ Phone: _________________________ E-Mail: ___________________________________ Mail to: Mid-America Public Health Training Center (MAPHTC) UIC- School of Public Health 1603 W. Taylor Street, M/C 923 Chicago, IL 60612 Attn: Fasika Alem For more MAPHTC Publications or to purchase publications online, visit our website: http://maphtc.uic.edu/Public/ Public Health Practice in Illinois (formerly Illinois Morbidity and Mortality Review) Guidelines for submissions Text 9 Articles must be submitted in electronic format, either on a disk, or using e-mail attachments to falem1@uic.edu. Acceptable file formats for text submissions are WordPerfect, Microsoft Word, ASCII or ANSI generic wordprocessor files. 9 Do not submit delimited text files or Apple/Mac wordprocessor files. 9 Filenames for electronic submission should begin with the first four letters of the principle author's surname. 9 Authors are responsible for the veracity and distribution of information in articles they submit. 9 The Mid-America Public Health Training Center presupposes that articles submitted have been approved for release by the agency (ies) with which authors declare their affiliation. 9 Articles can be 2 to 9 single-spaced pages. 9 Hard copies can be faxed to 312/996-5768 or mailed to: Fasika Alem, MPH Publications Manager Mid-America Public Health Training Center UIC- School of Public Health, M/C 923 1603 W. Taylor Street Chicago, Illinois 60612-4394 Formatting 9 A working title should be the first thing on the first page, followed by a draft date. 9 Contact information, including address, phone, and email should be on the first page. 9 The names, degrees and affiliations of all authors should appear on the front page. 9 Hard copies should be page numbered. 9 Do not use headers or page numbering on electronic file submissions. 9 Documents should be spell-checked by the authors. 9 Tables, charts, illustrations and graphics should be separate files. References 9 References should be part of the text file. Use of footnotes, endnotes or self-formatting add-ins such as End-Note is discouraged. 9 Citations should be by (author's surname, year) or (first author surname et al, year). References at the end of the article should be alphabetized by the principle author's last name. 9 Numbering in brackets (e.g. [1]) may be used in place of (author name, year) citation style in the text. In this case, sequential unparenthesized numbers should precede the alphabetized references listed at the end of the article. 9 References should be in the following format: Authors. Year. Title. Source Journal or Book . Examples of citation from Periodicals: CDC. 1981. Heat-related Illnesses and Deaths -- United States. Morbidity and Mortality Weekly Review. June 30; 44(25):465-8. Green LW, Iverson DC. 1982. School Health Education. Annual Review of Public Health. 3:321-38. Kessler RC, Cleary PD. 1980. Social Class and Psychological Stress. American Sociological Review. 45(3):463-78. Example of citation from Book Chapter: Kasl, SV. 1983. Social and Psychological Factors affecting the Course of Disease: An Epidemiological Perspective. In Handbook of Health, Health Care, and Health Professions, pp. 683-708. Ed. D Mechanic, New York: Free Press. Examples of citation from Books or Monographs: Green, LW, Kansler CC. 1980. The Professional and Scientific Literature on Patient Education. Detroit: Gale Res. Co. Squyres, WD, ed. 1980. Patient Education: An Inquiry into the State of the Art. New York: Springer. Public Health Practice in Illinois (formerly Illinois Morbidity and Mortality Review) Mid-America Public Health Training Center journals each focus on a particular topic. Following is a list of some of the interest areas that have been addressed by this publication: Volume 1: 9 Flood of 1993 9 Cancer 9 Behavioral Risk Factor Surveillance 9 Diabetes Volume 2: 9 Tuberculosis 9 Maternal & Child Health 9 Injury Control Volume 3: 9 Cardiovascular Health 9 Oral Health 9 Heat 9 Veterans in the Community Volume 4: 9 Indoor Air Quality and Asthma 9 Hispanic Health 9 Dental Public Health 9 HIPAA in Illinois Monographs: 9 Historical Epidemics in Illinois Volume 5: 9 Evidence-Based Public Health 9 An Illinois Public Health Nursing Initiative 9 Environmental Contaminants 9 IIMCHL Projects Volume 6: 9 Public Health and Corrections 9 Addressing Rural Health Disparities in Illinois Upcoming Issues: 9 Childhood Obesity/Overweight 9 Diabetes 9 Performance Standards 9 Minority Health 9 Aging 9 Tobacco Control 9 Women’s Health 9 Sports Injuries 9 HIV/AIDS 9 Violence 9 State laboratories and local solutions 9 Disasters - warning and follow-up 9 Foodborne outbreaks We invite contributions from the public health community. Potential authors with experience in these areas of endeavor are invited to call us. We also welcome ideas for new topics for the future. Public Health Practice in Illinois is not strictly a peer reviewed academic journal. We are interested in good and accurate reporting. Most of our articles can be classified as one of the following: case studies, description of successful or model programs, history, epidemiology, or policy interpretation. Most readable articles are about 5 pages in length. Graphic interpretation of statistics are useful and welcome. Submission guidelines are on the next page. We are happy to discuss your ideas, and provide editorial support when needed. Earn a Free Subscription by writing! Public Health Practice in Illinois Mid-America Public Health Training Center The University of Illinois at Chicago School of Public Health, M/C 923 1603 W. Taylor Street Chicago, IL 60612