Rural Women's Health Conference Summary Report Summary Report  (PDF File, 1.82 Mb) August 13 -15, 2007 Omni Shoreham Hotel, Washington DC

Workshops, Part I

Improved Quality of Life Through Weight Management

This presentation focused on an approach to helping fight obesity in the setting of a rural clinician. Wendel J. Ellis, D.O., Greeley County Health Services, started this informal program upon noticing that his prescriptions of diet and exercise were ineffective and that more people coming to the clinic with obesity were also suffering from depression.

Dr. Ellis opened his presentation by noting that obesity affects over 108 million Americans and greatly increases health risks for many conditions, including hypertension, type 2 diabetes, coronary heart disease, gallbladder disease, certain cancers, dyslipidemia, stroke, osteoarthritis, and sleep apnea. Obesity is defi ned as having a Body Mass Index (BMI) of 30, or higher. Dr. Ellis noted that in adults ages 20-74, the rate of obesity has risen from around 15 percent in 1976 to over 30 percent in 2003. As measured by the CDC's Behavioral Risk Factor Surveillance System, in 1995, no States had an obesity rate above 20 percent of the population. However, by 2000, 22 States had obesity rates over 20 percent.

Dr. Ellis explained that one of the reasons for the increase in obese adults in America is the increase in the size of servings. He then presented a series of slides, produced by the CDC, comparing the average number of calories in portions 20 years ago to the number of calories today. Due to the increase in portion sizes, Dr. Ellis noted that people ingest many more calories than 20 years ago, contributing to the increase in the number of obese Americans.

Dr. Ellis outlined the four different types of therapy for obesity:

1. diet and exercise
2. pharmacotherapy
3. behavioral therapy
4. surgery.

Dr. Ellis then described the details of the program he has initiated in Greeley County, Kansas. After he sees a patient and diagnoses obesity, a variety of things happen. First, Dr. Ellis will work with a Registered Nurse (RN) to help educate the patient and develop a plan of action to help induce behavioral change. Dr. Ellis has taken the position that obesity is an ongoing condition, like diabetes, that cannot be addressed in one treatment cycle.

After the initial visit, the RN schedules weekly appointments with patients, providing emotional support and accountability to patients. The RN also helps patients keep food diaries, develop exercise programs, and set realistic weight-loss goals of 0.5 pounds per week.

In closing, Dr. Ellis presented testimonial letters from two of his patients who had managed to lose over 50 pounds each. Both mentioned the positive effects of a daily exercise routine and the importance of changes in lifestyle, as well as the enormous importance of the RN in helping them get through tough times in the program.

Health Experiences of Women Living in Rural/Frontier Communities

This presentation summarized the fi ndings of a study supported and conducted by the Wyoming Health Council from 2006 to 2007 to explore the health-related experiences of women living in rural/frontier Wyoming. Susan McCabe, Ed.D., APRN, BC, Associate Professor, School of Nursing, University of Wyoming, and Corinna Seely, B.S., Contractor at the National Rural/Frontier Women's Health Coordinating Center, Wyoming Health Council, opened the presentation with an overview of the study.

Dr. McCabe and Ms. Seely noted that the researchers designed a qualitative study in which the main data collection method was focus groups. In addition, a nested study was conducted using photo-voice methodology, a process through which participants are given disposable cameras and asked to take photos of things in their communities that represent health to them. Once the photos are developed, the researchers discuss their meaning with the participants.

The major research question addressed by the study was:

• What is the experience of health for a woman living in rural/frontier Wyoming?

Sub-questions included:

• What are the main health concerns of women living in rural/frontier communities?
• What are the supports and barriers to health?
• What is the impact of the experience of living in rural/frontier communities on women's access to care?

The focus groups were conducted in six communities in Wyoming, representing various aspects of the State, including geographic region, economic base, and population diversity. Dr. McCabe and Ms. Seely noted that a "snowball" process with key informants was used to recruit women for the focus groups in each of the six communities. A total of 45 participants were recruited, ranging in age from 19 to 64, with an average age of 41 years. Ethnicity was self-reported, with approximately onetenth reporting as Hispanic, and the remaining nine-tenths split evenly between white and Native American.

Dr. McCabe and Ms. Seely stated that the focus groups lasted between 50 and 80 minutes. Audio and video recordings were made of each session and researchers compiled fi eld notes. In addition, participants completed health assessment surveys. The researchers also collected data from other sources, such as the chamber of commerce/visitor information center, newspapers, and phonebooks, as well as community photos. A mid-process review was conducted to determine whether changes to the protocol were necessary. As a result of the review, the researchers put more stress on the confi dentiality of collected information, given the personal nature of the information discussed and the closeness of the rural communities.

The fi ndings identifi ed fi ve main concerns that were consistent across all six groups:

• Lack of health insurance and ability to pay for health care
• Strong sense of own expertise in personal health and health-related issues
  
• Competing needs related to the health of family members
  
• Unavailability of quality mental health care
  
• Difficulty of remaining healthy in a rural environment

Dr. McCabe and Ms. Seely noted that the participants identifi ed several factors that support good health, including the rural lifestyle, which typically has less stress and is characterized by a more supportive community; meaningful personal supports, such as the church, family, animals/pets, and nature; the importance of personal independence and self-reliance; and easy access to health information, most often via the Internet. Participants also identifi ed several barriers to good health, including the rural environment, especially the diffi culties of travel (e.g., distance, time, and cost); environmental pollutants; disrespect and cultural bias on the part of providers; the fragmented nature of care (i.e., having to travel to multiple sites to obtain services); and limited care options.

The overarching fi ndings from the study were:

• Women are "straddling the line"—at any moment something could happen that could result in catastrophe.
• Rural areas were perceived as both the best and the worst place to be in terms of health.
• Many factors affect overall health and access to health care.
• Women are responsible for their own health and the health of their families—they are the "glue."

Women's Behavioral Health Systems Building: Innovative Ideas for Local and State Collaboration

This presentation showcased an innovative women's behavioral health program from Maine. Anne Conners, M.A., B.A., Project Specialist at the Muskie School of Public Service, University of Southern Maine, began the presentation by noting that substance abuse and depression are growing problems in the State of Maine. Issues include prescription drug abuse and binge drinking. In addition, Ms. Conners noted that one in fi ve Mainers report experiencing depression. To help address these issues, Maine received a Women's Behavioral Health Grant from the HRSA Maternal and Child Health Bureau's Division of Perinatal Systems and Women's Health.

Ms. Conners explained that the vision of Maine's Women's Behavioral Health initiative was to integrate screening for depression and substance abuse for women of reproductive age into the primary care setting in rural underserved areas. She went on to explain that the program targets areas from all over the State. One of the project highlights is that it aims to involve systems, not just health centers. It also emphasizes public-private organizations and the involvement of grassroots organizations. In addition, because the HRSA grant is nonrefundable, there is a large effort to build sustainability.

Ms. Conners stated that project designers selected four primary locations in four counties. Since the State of Maine is the largest of the New England States, some sites are as far as a 5- or 6-hour drive apart, and distance is a constant challenge. The program designer's methodology included three coordinating entities—the Women's Behavioral Health Grant Steering Committee, the Women's Behavioral Health Systems Initiative Advisory Group, and the Demonstration Sites Leadership Team. Each of the three entities contributed something unique to the project.

Ms. Conners noted that although the project is still in progress, they have already learned many valuable lessons. Maine has a strong sense of community—people really do pitch in and help each other. The health centers ended up sharing information and resources, rather than competing with each other. If one health center had a good idea, it would share it with another. Another thing they discovered was that women were more likely to come to an event if there was a connection to their children.

In closing, Ms. Conners stated that one of the most exciting outcomes of the program is that all four health centers plan to do universal screening. Their fi rst step is to implement the screening for chronic disease patients. It is important to acknowledge that although the process is diffi cult, what helps is having support along the way. They have also achieved policy changes—their project was written into the State health plan.

Integrating Cognitive Behavioral Therapy in Primary Care Treatment of Depression and Anxiety for Rural Women

Dr. McDaniel began by noting that Radford University is located in the Blue Ridge Mountains of Southwest Virginia, approximately 13 miles from Virginia Tech. There are numerous challenges to providing mental health care in the area, including a lack of insurance and a lack of providers. Many primary care providers and nurses are not trained as counselors. In addition, there is a lot of stigma associated with mental health in rural areas. Transportation is also a problem, and there are long waits for appointments. Dr. McDaniel explained that Radford University received a grant from the Virginia Health Care Foundation to educate providers in CBT. She went on to explain that CBT is a psychotherapeutic model that engages the client in a collaborative manner to examine the way she constructs and understands her world (cognitions), evaluate the process by which the individual acts on cognitions (behaviors), and challenge targeted behaviors and cognitions to gradually change a client's way of thinking, behaving, and interacting. Dr. McDaniel noted that once you can modify the way of thinking, it results in symptom improvement.

Dr. McDaniel outlined the three program objectives:

1. Identify mental health needs of rural women
2. Discuss cognitive behavioral strategies appropriate for primary care
3. Discuss issues in providing CBT in the primary care setting

Dr. McDaniel then explained that the university developed a three-credit course that focused on preparing advance practice nurses (APN) to provide CBT. Eleven providers participated in the three-credit course. Overall, 717 women and men were screened for depression, and 480 were screened for anxiety. Of those screened, 168 were recommended for further mental health services, which was mostly CBT.

Ms. LaRue then summarized some of the issues they encountered regarding CBT in primary care. They included commitment, integration, time factors, and dealing with CBT codes and documentation. Next, Dr. Strauss walked participants through a sample screening.

Dr. McDaniel concluded the presentation by summarizing the outcomes and fi ndings. She noted that CBT was provided for 57 women experiencing depression and anxiety over a period of 7 months. Seventy-fi ve percent of the clients experienced decreased depression and anxiety scores and adhered to their medications.

Dr. McDaniel stated one key fi nding was that those with high Beck Depression Index and Beck Anxiety Index scores could be handled in the primary care setting if there was no threat of harm to self and others. In fact, she noted that most clients rejected referral to outside settings and wanted to stay inside the primary care setting. The staff also found that clients had an improved ability to identify and use resources. Dr. McDaniel explained that the clients were better equipped to make decisions about their care. When confronted with new challenges, they self-referred themselves back to the primary care provider.

Before It Starts: Domestic Violence Prevention in Rural, Frontier, and Geographically Isolated Communities

This workshop provided an overview of the DELTA (Domestic Violence Prevention Enhancements and Leadership Through Alliances) approach to domestic violence prevention. It was presented by Joshua Edward, M.H.P. (in progress), DELTA Project Coordinator, Alaska Network on Domestic Violence and Sexual Assault; Karen Lane, M.Ed., State DELTA Project, Coordinator, Montana Coalition Against Domestic and Sexual Violence; Janelle Moos, M.S., DELTA Project Coordinator, North Dakota Council on Abused Women's Services; and Jennifer Wages, M.S.W., LCSW, Project Coordinator, Center for Rural Health.

The presenters began by explaining that the DELTA initiative is the CDC's primary domestic violence prevention effort utilizing a public health approach to address intimate partner domestic violence. The initiative includes 14 State Domestic Violence Coalitions and focuses on preventing fi rst-time perpetration and fi rst-time victimization.

The presenters noted that intimate partner domestic violence is defi ned as physical violence, sexual violence, threats of physical or sexual violence, psychological/ emotional abuse, and stalking between current spouses, former spouses, current non-marital partners, and former non-marital partners. Many practitioners and researchers use the term "domestic violence" rather than the term "intimate partner violence" to refer to the same public health problem. The presenters explained that the DELTA program uses the term "intimate partner violence" to clarify that this program does not address other public health problems that are also referred to as domestic violence (e.g., child abuse and elder abuse by relatives other than an intimate partner).

DELTA is a population- and environmental-based system level of services, policies, and actions that prevent intimate partner violence from initially occurring. It uses a community level process to identify risk factors and maintain prevention implementation.

At its core, the presenters explained that the DELTA program is a collaborative community-based effort that incorporates sustainability from the very beginning of the initiative. It views sustainability not as getting funding, but as planning and supporting efforts to incorporate prevention initiatives into existing community institutions; making policy changes in the rules, regulations, and laws of the community; mobilizing community residents to own and lead prevention efforts; and fi nding sources of revenue to support ongoing activities of the effort. Its goal is to bring about long-term success by effecting social change.

Listen to Women: Meeting the Needs of Rural Women

This presentation highlighted approaches for providing gender-appropriate care through health provider recruitment and retention. Jill Alliman, M.S.N., CNM, Center Director and Nurse Midwife at the Women's Wellness and Maternity Center National Rural/Frontier Women's Health Coordinating Center, and Julia Phillippi, M.S.N., CNM, Lecturer at Vanderbilt University, began by explaining that "Listen to Women" is a slogan designed to remind providers to listen to the women they serve.

Ms. Alliman and Ms. Phillippi explained that two primary questions health care providers must ask are:

1. Do women have the services they need?
2. Do they feel "heard"?

Ms. Alliman and Ms. Phillippi asserted that these questions matter to women, because there is a shortage of care, and women are the gatekeepers. They often make health decisions for multiple generations. We need to provide gender-appropriate care and reduce the stigma of access to care. Ms. Alliman and Ms. Phillippi noted that the shortage of care also matters to providers. They explained that because of the shortage, there is an increased load on existing providers, in addition to the fi nancial burden of care, the malpractice crisis, and wanting to meet the client's needs.

Ms. Alliman and Ms. Phillippi noted that the Women's Wellness and Maternity Center was established 23 years ago in response to the shortage of care in the area. It was established primarily for prenatal care and delivery services, but has added more services over the years. Through its designation as an RFCC, the Center has expanded its focus to include increased primary care, a continued emphasis on gender-based care, a referral and tracking system, leadership development, community outreach, and research and data collection.

The presenters explained that as we look at ways to increase access, we need to look at providers' scope of care. Several national organizations have information on provider scope of care on their Web sites. They noted that providers can also turn to State organizations and boards that regulate practice. They asserted it is especially important to look at reimbursement rates and the larger regional network. Just because something does not work now, does not mean it will not work 5 years from now. They emphasized that providers must keep trying.

Ms. Alliman and Ms. Phillippi suggested that when providers look at their facilities' scope of care and what they can add, they need to think out of the box. They explained a clinic may be really busy, but it may be possible to add a nutritionist—she really only needs a desk and two chairs. They went on to suggest that providers can also look at expanding hours—many women are willing to work at the facility into the evening, when their husbands can take care of the children. The presenters explained the challenge is sustaining the model over time. Providers should be encouraged to think of their model as dynamic and to think outside of the walls of the clinic.

Women Health Providers for Rural Communities: Supportive Networks to Ensure Recruitment and Retention

This presentation highlighted one center's perspective on achieving gender-appropriate provider recruitment and retention. Barbara Levin, M.D., M.P.H., Medical Director of the Women's Wellness and Maternity Center, began by noting that the retention and recruitment process for fi nding and keeping women providers in rural communities is an ongoing challenge. When Dr. Levin attended medical school, approximately 3—7 percent of students were women. Women now represent over 50 percent of students in medical school, and more women choose primary care specialties. However, Dr. Levin noted, fewer women choose rural practice than men.

Dr. Levin explained that the future impact of this issue is that more women in primary care may mean fewer providers in rural communities. Yet, she noted, documents show that very few people are dealing with the issue on a policy level. The World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) issued a resolution in 2000 stating, "Rural practice should refl ect the way women experience their lives." Dr. Levin explained this issue is important, because we frequently have to innovate. We need to think outside of the box, because in rural places, there is not a box (e.g., a dental center in a health clinic).

Dr. Levin stated that in Monroe County, Tennessee, non-physician providers include 4 dentists (2 have stayed and 2 have left), 20-plus nurse practitioners (11 are still in practice), and 14 Certifi ed Nurse Midwives (4 are still in the county). Dr. Levin then introduced her intern, Alana Sagin, a second-year medical student at Jefferson Medical School in Philadelphia, PA, who conducted a pilot study of two East Tennessee counties on the issue of recruitment and retention.

Ms. Sagin presented the results of her study. She began by explaining that she developed a questionnaire, which she followed with a face-to-face interview with 20 percent of respondents. One thing she learned immediately is that reasons for coming to the county and reasons for staying were fairly similar. She noted that one of the most common issues was spouse/work opportunities. Other important issues were diffi culties adapting to small-town life.

Dr. Levin then noted that nearly all women surveyed had heard about the Women's Wellness and Maternity Center. It was clear that Monroe County had become a place where you go for women's health concerns, which was due in large part to the Center's work.

Dr. Levin discussed how she started conducting Leadership Luncheons to help health care providers recognize that they are part of a larger network. She noted that nurse midwives and practitioners were more likely to participate in the luncheons than physicians and dentists, which is evidence that there is still a great need for cross-discipline interaction. Dr. Levin concluded by explaining that when you are looking for women providers, it is very important that they are embedded in the network.

Bridging Gaps in Access and Quality for Women Through Telehealth Programming in a Rural Federally Qualifi ed Health Center

This presentation demonstrated how telehealth can be used effectively to improve health care for rural women. Juliana Anastasoff, M.S., Chief Project Offi cer at El Centro Family Health and Director of the National Rural/Frontier Women's Health Coordinating Center, began by noting that El Centro Family Health serves a 7-county region of 23,000 square miles with a population density of 0.05—12.1 percent. She explained that the region is characterized by remote mountain villages, many of which lack public infrastructure. For most of the year, road conditions are poor at best and even hazardous during certain times. In the region, 70 percent of the population is at or below 200 percent of the poverty level, and 43 percent is uninsured. Ms. Anastasoff noted that all but one of the 33 counties in the region is classifi ed as an HPSA.

Ms. Anastasoff reported that El Centro received a grant from the NRHA to fund a program that provided technical assistance for the development of telehealth capabilities. Telehealth was an attractive option to El Centro because it can be a useful tool to reduce health disparities; maximize effective utilization of resources; reduce isolation of rural clinicians; facilitate the practice of evidence-based medicine; and enable continuous quality improvement.

Ms. Anastasoff explained that the NRHA grant enabled El Centro to hire a highly qualifi ed consultant to help them with this effort. They identifi ed patient needs through surveys, charts, and meetings with the community, and provider needs through focus groups. El Centro also assessed its own needs by consulting middle managers, senior leadership, clinical leadership, and the Board of Directors.
The fi nal plan prioritized:

• Tools to assist clinicians in making decisions
• Access to specialist care
• Communication between rural health providers
• Improved internal communication
• Improved management of patient data

Ms. Anastasoff went on to explain that the technology they identifi ed for achieving these objectives included electronic health records, mobile computing devices, wireless Internet access, and videoconferencing. Another technology-related effort of El Centro is its Web portal targeting women and girls. Currently, it serves 1,300 users. She concluded by noting that the Web-based approach is especially good for rural teens, since many of them are very isolated.

Telehealth: Shrinking Barriers and Expanding Opportunities for Health Care

This presentation highlighted an innovative telehealth network in the State of Utah. Deborah LaMarche, B.S., Program Manager at the Utah Telehealth Network (UTN) began by stating that UTN's mission is to expand access to health care services and resources within Utah and the intermountain West through the innovative use of technology. UTN was initiated in 1996 and is operated by the University of Utah. The network is open to any Utah healthcare provider and there are currently over 40 members.

Ms. LaMarche explained that telehealth is defi ned as the use of electronic information and telecommunications technologies to support distant clinical health care, professional health-related education, public health, and health administration. Telehealth includes videoconferencing, teleradiology, telepharmacy, remote monitoring, and home health. It allows for real-time, interactive communications, is user-friendly, and is typically rated positively in patient satisfaction surveys.

Ms. LaMarche noted that while patients report telehealth is not as good as seeing a provider face-to-face, they find it much better than having to drive long distances to see a provider. In Utah, telehealth has resulted in less isolation, travel, and waiting by patients, as well as improved access, quality, value, and continuity of care.

Next, Donna Jensen, Women's Health Director of the Utah Navajo Health System National Rural/Frontier Women's Health Coordinating Center, stated that one example of UTN's partners is the Utah Navajo Health Association (UNHA), a federally designated 330e community health center that provides medical, dental, and behavioral health services. UNHA uses telehealth for telepharmacy, services such as retinal eye exams, echocardiograms, and x-rays. Ms. Jensen explained that an important component of UNHA's services is the use of electronic medical records, which allows providers across sites to access patients' medical records and facilitates tracking of services.

Since initiating the system more than 10 years ago, Ms. Jensen reported that UTN has learned important lessons related to all aspects of telemedicine. She noted that there are a variety of strategies for optimizing telehealth, depending on the setting. For example, with patient care, it is important to ensure that there is written consent from the patient, and that providers introduce everyone in the room and do not allow any interruptions. Ms. Jensen concluded by stating that telehealth is also very effective in educating providers. She asserted that such techniques will make educational opportunities available to many more providers and potential providers.

Cancer Suvivorship in Rural Communities

This presentation summarized research on rural cancer survivors. Camille T.C. Hammond, M.D., M.P.H., a Program Director at the University of Maryland School of Medicine in the Offi ce of Policy and Planning, began by noting that cancer survivors have been tracked as a group since 1971. She stated that in the broadest defi nition, anyone diagnosed with cancer is a cancer survivor from the time of diagnosis to death. Some defi nitions also include caregivers and family members of diagnosed cancer patients as cancer survivors.

Dr. Hammond reported that around 10.7 million Americans are cancer survivors, which is about 3.6 percent of the population. She explained that the number of cancer survivors has increased over time because of increased accuracy in detection, more effective treatments for cancer, better supportive care, and better long-term surveillance. Cancer has become more of a chronic illness, rather than a death sentence, that is addressed within the community (not as many trips to out-of-town specialists).

Dr. Hammond explained that rural cancer survivors have increased risks for poor outcomes, such as second primary cancers, late physical and psychological effects of cancer and its treatment, unemployment following cancer diagnosis, and dealing with role adjustment (especially rural women, who feel being a patient interferes with nurturing social roles). Oftentimes, rural cancer survivors deal with senses of helplessness, hopelessness, posttraumatic stress disorder, lack of emotional support, and the physical distance from adequate care and information.

Dr. Hammond noted that rural caregivers (the informal support provided by family and friends) also need help due to limited access to healthcare services, transportation problems, and geographic/social isolation. They need clear and consistent messages about treatment goals and better coordination between healthcare services.

Dr. Hammond said that healthcare providers noted the need for training in treating cancer survivors. Many primary care doctors are unaware of the possible side effects and long-term health issues associated with specifi c cancer treatments. She reported that providers also suggested a "care plan" be given to patients following cancer treatment, so they are always aware of the treatments used, type of cancer treated, possible late side effects, and additional information that would be useful for other doctors to know before treating the cancer survivors.

Dr. Hammond concluded by stating that survivors want to know how to reduce the effects of cancer, how to decrease their risk of developing new cancers, and where they can fi nd doctors familiar with late-term cancer effects. In the future, we need interventions to improve quality of life for underserved cancer survivors, provide support for informal caregivers, and train doctors to increase awareness about evidence-based followup care.

Poverty and Community Food Resources as Determinants of Insuffi cient Household Food Resources Among Rural Women

This presentation summarized the fi ndings of studies on rural women's nutrition. Joseph Sharkey, Ph.D., M.P.H., RD, Associate Professor at the School of Rural Public Health, Texas A & M Health Science Center, Social and Behavioral Health Department, opened the session by noting that rural women have many challenges to a healthy lifestyle, including high levels of chronic conditions, low levels of available health support, poorer housing, limited transportation, and limited access to resources and programs.

Dr. Sharkey explained that healthful eating training is focused on the individual choice level, without taking into account issues of adequate resources, food environment, and food security/food suffi ciency. He went on to explain that connecting the Brazos Valley Health Status Assessment (BVHSA) and the Brazos Valley Food Environment Project (BVFEP) allows a snapshot of rural women's health to be studied in the context of physical surroundings.

Dr. Sharkey stated that the BVHSA surveyed over 2,000 individuals, of which over 60 percent were rural inhabitants. Of rural participants, 73 percent were women. Many households had children, and many also had nutrition-related conditions, like diabetes, obesity, heart issues, and hypertension. He noted that the survey found that rural women had higher percentages of food insecurity (ran out of food, no money for more); unbalanced meals based on cost (too expensive to eat healthy); and skipping meals to spread out food supplies. Rural women also reported a much higher feeling of dissatisfaction with the variety of choices available, number of stores nearby, and food cost.

Dr. Sharkey explained that the BVFEP mapped all of the food stores available in the area by satellite and allowed researchers to see where respondents lived in relation to store locations. Forty-one (41) percent of rural women lived 10 or more miles one way from the nearest supermarket, whereas most lived closer to a convenience or small grocery store. Because the area has no public transportation, access to different types of food supplies severely limits food choices for many. Since supermarkets are hard to access, rural women face higher food costs, less healthy food choices, less fresh food, and increased risk of inappropriate food choices. Rural women also are at a higher risk for increasing levels of insuffi cient household food resources due to limited fi nancial resources, children at home, and limited community food resources.

Dr. Sharkey concluded by stating that the findings of these studies suggest that there needs to be an increased focus on rural areas and rural women. He noted that they also suggest the importance of comprehensive community health assessments that include the context in which people live, including households, neighborhoods, and communities.

Promoting Heart Health in Rural Women: The Halfway Perspective of an Intervention Study

This presentation summarized the preliminary fi ndings of a study being conducted on rural women's heart health. It was presented by Pamela Stewart Fahs, D.S.N., Associate Professor, Endowed Decker Chair of Rural Nursing and Health at the Decker School of Nursing, and Margaret Pribulick, RN, a student in the Rural Nursing Ph.D. Program, both of Binghamton University. Dr. Fahs and Ms. Pribulick began by stating that the New York Women's Health Care Partnership, based at Binghamton University, and a research team at the University of Virginia are conducting an intervention study to determine whether rural women receiving Stage Matched Nursing & Community Intervention (SMNCI) have greater lifestyle behavior changes to support heart health than women who receive only Community Intervention (CI).

Dr. Fahs and Ms. Pribulick explained that the study is looking for measurable differences in SMNCI vs. CI in dietary, smoking, and physical activity of rural women in Orange County, VA, and Delaware County, NY. The presenters noted that the outcomes to be measured include:

• Stage of change (SOC) for each behavior—diet, smoking, and physical activity
• Movement in SOC over time
• Change in modifi able physiologic and cardiovascular risks (BP, BMI, Lipids, C-Reactive Protein, Framingham Coronary Heart Disease Risk Score)

Dr. Fahs and Ms. Pribulick noted that many of the women participating in the study felt they were already in the action or maintenance stage in one or more behaviors. Seventy-six (76) women self-reported action in diet (eating 5 or more fruits and vegetables per day), while 24 women said they had stopped smoking more than 6 months ago (maintenance) and 44 reported they had 30 minutes of physical activity on 3 or more days of the week.

Dr. Fahs and Ms. Pribulick explained that enrollment in the intervention study is three-quarters complete, and researchers are just receiving the 7-month questionnaires for the fi rst enrollees. Before any speculation about changes or results can be reported, the next 7-month questionnaires are needed. The presenters went on to explain that what the study does present is that the women enrolled are overweight, have one or more behavioral issues, show beginning level risk factors, and have more abnormal electrocardiograms (ECGs) than expected. They concluded by noting that while there is currently not enough data to indicate that there are stage changes for any of the behaviors or changes in the physiologic outcomes that are normally associated with cardiovascular risk, what can be said is that the women have increased their healthy behaviors just by being part of the study.

Going Red in Rural West Virginia

This presentation summarized the fi ndings of a pilot project on women's heart health. It was presented by Elaine Bowen, Ed.D., West Virginia University Extension Specialist—Health Promotion at the Extension Service National Center of Excellence in Women's Health, and Sharon Brinkman-Windle, M.P.A., M.A., West Virginia University Mary Babb Randolph Cancer Center. Dr. Bowen and Ms. Brinkman-Windle began by explaining that the West Virginia Women Wear Red for Heart Health Pilot Project uses an aggressive, yet personal, woman-to-woman approach to bring culturally appropriate heart health information to rural women through a variety of communication channels

Dr. Bowen and Ms. Brinkman-Windle reported that the fi rst step of the project was to create a community advisory board, consisting of community stakeholders such as CEOs, university stakeholders, local opinion leaders, and local health entities—to explore what women would want in an education program. The group then conducted various focus groups to learn from women in the community their experiences with heart health messages and care, explore what they thought a successful heart health education event would look like in their community, and what they thought was important to know about heart health.

Dr. Bowen and Ms. Brinkman-Windle stated that from this information, the project organizers developed four main events:

• A Heart of the Mountain video that presented stories of West Virginia women who were heart disease survivors
• Heart Health is Fashionable—a health education lunch and fashion show
• Training events for extension personnel on how to hold "Love Your Heart Talks" for heart health education
• Media outreach timed to correspond with the American Heart Association Go Red campaign

Dr. Bowen and Ms. Brinkman-Windle reported that the response to all methods of community communication was overwhelmingly positive. Women indicated they liked the focus groups as an opportunity to shape the events. Women connected with the stories in the Heart of the Mountain video and could identify with the survivors. The video was featured at American Heart Association media events and distributed to 173 public libraries.

The pre- and post-tests from the Heart Health Is Fashionable events showed signifi cant changes on all metrics used and was replicated to reach a total of 401 women. The training in Love Your Heart Talks reached 12 women in Wood County, and 16 community organizers were trained at statewide training, who will then train women in their communities.

The presenters concluded by reporting that the program has ongoing support from the American Heart Association and additional community trainings are scheduled. In addition, the results of the pilot will be published in scholarly journals and the State Medical Journal.

Current as of October 17, 2008