1. Kate Beatty, PhD, MPH Assistant Professor College of Public Health, East Tennessee State University Educational background: MPH with a dual concentration of behavior science and health education and epidemiology and PhD in Public Health Studies at Saint Louis University's College for Public Health and Social Justice. Research interests: public health services and systems research, performance management, accreditation standards, rural public health, & coordination of public health and primary care. Rural projects: Reducing Childhood Obesity and Chronic Disease in Central Appalachia (Current) Accreditation of rural health departments: social, economic, cultural and regional factors (Previous)

2. Local Health Department (LHD) Clinical Service Delivery along the Urban/Rural Continuum

3. Overview of the Presentation Background Research Question Data Sources Methods Results Conclusion

4. Background Rural LHDs face many challenges including lower levels of staffing and funding than LHDs serving metropolitan or urban areas. – Their populations experience health disparities related to risky health behaviors, health outcomes, and access to medical care.

5. Background LHDs serving rural communities have lower levels of staffing and funding to meet their community needs. The number and types of community organizations (hospitals, health clinics, not-for- profits), available to partner with may be limited based on geographical isolation. These factors may affect the availability of clinical services in rural communities.

6. Research Question Do levels of LHD clinical service delivery differ based rurality?

7. Data Sources 2013 NACCHO National Profile of Local Health Departments Study (2013 Profile Study) Rural/Urban Commuting Area (RUCA) Codes

8. Rural/Urban Status LHDs were coded as “urban”, “micropolitan”, or “rural” – RUCA codes for LHD zip code. – Micropolitan includes census tracts with towns of between 10,000 – 49,999 population and census tracts tied to these towns through commuting. – Rural includes census tracts with small towns of fewer than 10,000 population, tracts tied to small towns, and isolated census tracts. Both “micropolitan” and “rural” categories are considered rural by the Federal Office of Rural Health Policy.

9. Clinical Services “For each activity, check whether and how your LHD provided that activity or service in your jurisdiction during the past year.” 1.Performed by LHD directly 2.Contracted out by LHD, or 3.Provided by others in community independent of LHD funding.

10. Clinical Services Clinical services included: – immunizations; – screenings; – treatment for communicable diseases; – maternal and child health; and – other services

11. Analysis Bivariate analysis – Clinical services offered by rural/urban status of the LHD jurisdiction.

13. Performed by LHD directly UrbanMicropolitanRural Immunizations Adult84.596.193.0** Childhood80.296.393.3** Screenings HIV/AIDS60.969.454.4** Other STDs57.673.162.0** Tuberculosis77.189.387.5** Cancer31.345.633.7** Cardiovascular disease25.431.827.1* Diabetes33.135.631.2 Blood lead52.767.962.0** Maternal and Child Health Family planning38.170.557.7** Prenatal care27.227.525.6** EPSDT21.543.140.3** WIC54.672.768.4** Other Health Services Comprehensive primary care9.7147.5** Mental health services10.513.38.5* Substance abuse services9.28.23.9**

14. Provided by others in community UrbanMicropolitanRural Immunizations Adult55.551.550.1 Childhood59.152.645.4** Screenings HIV/AIDS70.159.354.7** Other STDs64.956.458.1** Tuberculosis51.65338.1** Cancer85.979.678.6** Cardiovascular disease82.188.381.1* Diabetes78.181.280.6 Blood lead64.562.551.5** Maternal and Child Health Family planning77.065.559.4** Prenatal care82.187.267.8** EPSDT62.662.845.8** WIC40.633.929.3** Other Health Services Comprehensive primary care89.290.793.0* Mental health services90.594.788.2** Substance abuse services90.196.785.0**

15. Contracted by LHD UrbanMicropolitanRural Immunizations Adult6.31.40.5** Childhood7.20.01.2** Screenings HIV/AIDS10.04.84.1** Other STDs9.42.73.7** Tuberculosis6.61.21.9** Cancer5.04.41.4** Cardiovascular disease3.40.01.4** Diabetes4.30.00.7** Blood lead6.52.21.3** Maternal and Child Health Family planning5.14.76.6 Prenatal care5.24.32.9** EPSDT3.30.03.8** WIC4.42.02.9 Other Health Services Comprehensive primary care3.71.30.3** Mental health services6.52.62.0** Substance abuse services5.31.01.9**

16. Conclusion For many services, rural LHDs are less likely to offer, contract or have services provided by another organization in the community Whereas larger rural (i.e., micropolitan) jurisdictions are more likely to directly provide these services.

17. Conclusion Micropolitan LHDs may have greater infrastructure and capacity to deliver clinical services than those serving smaller jurisdictions. Health care reform brings threats and opportunities for LHD clinical service delivery. Lower levels of clinical service delivery by rural LHDs may contribute to the access issues facing rural communities.

18. Conclusion Further analyses to assess impacts on rural LHDs and identify strategies to help ensure access to clinical services is encouraged

19. Contact information For additional information about this study contact: Kate Beatty at beattyk@etsu.edu or 423-439-4482