INTERACTIONS OF INDIVIDUAL, FAMILY, COMMUNITY, AND POLICY CONTEXTS ON THE MENTAL AND PHYSICAL HEALTH OF DIVERSE RURAL LOW-INCOME FAMILIES

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: COMPLETE
• Funding Source: HATCH
• Reporting Frequency: Annual
• Accession No.: 1011394
• Multistate No.: NC-_old1171
• Project Start Date: Oct 24, 2016
• Project End Date: Sep 30, 2019
• Program Code: [(N/A)]- (N/A)

Recipient Organization
NORTH CAROLINA STATE UNIV
(N/A)
RALEIGH,NC 27695

Performing Department
Agricultural and Human Sciences

Non Technical Summary
Rural communities and families continue to experience health inequalities when compared to their urban and suburban counterparts. In fact, several measures (deaths related to cancer and hospital admission with pneumonia, as well as rates of obesity) indicate an increase in rural health disparities despite efforts to improve health care quality, access, and affordability among rural areas (AHRQ, 2012). a purposeful selection of families and community stakeholders across geographic regions will be conducted to understand potential impacts of the ACA on rural low-income familiesResidents of rural areas have unique issues and needs, including distinct health concerns. These health concerns are associated with multiple factors, including growing concentrated poverty in rural America, as well as an increase of racial/minority families in rural America who are at greater risk for health disparities. The poverty rate in rural America was 16.5% in 2006-2010 compared to 14.8% in 2000.This project will continue to carry the voice of rural families to policy makers, so that policy makers will be aware of the context of rural communities as it interfaces with policy. This project will examine rural low-income families' ability to access healthcare insurance through Affordable Care Act provisions. Equally important, it will examine access to medical care and individuals' understanding of and use of ACA provisions designed to make health care more affordable; such as, Advanced Premium Tax Credits and Cost Share Reductions to reduce out-of-pocket expenses. We will also look at who is insured and who is not insured, comparing individuals residing in states that enacted Medicaid expansion and individuals residing in states that did not enact Medicaid expansion.The research team is multidisciplinary and employs a framework focused on improving the health of rural families through examination of the strengths and challenges rural families face in obtaining optimal physical and mental health. Results from this study are anticipated to inform the work of researchers, extension and other educators, and community stakeholders as they further develop research agendas, as well as create products (e.g., curricula, programs, policy briefs) that recognize the unique context and needs of rural America to specifically address current challenges and barriers low-income rural families face in achieving optimal health. This project further extends the expertise of the land grant system to support prosperity in rural America.

Animal Health Component

90%

Research Effort Categories

Basic

10%

Applied

90%

Developmental

(N/A)

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
607	6199	3010	100%

Knowledge Area
607 - Consumer Economics;

Subject Of Investigation
6199 - Economy, general/other;

Field Of Science
3010 - Economics;

Keywords

rural

affordable care act

healthcare

low-income

Goals / Objectives
To understand the impact of the Affordable Care Act (ACA) on rural low-income families. To disseminate findings, based on the proposed analyses, in order to further the empirical knowledge base and increase understanding among family serving professionals and policy makers regarding factors that contribute to or create barriers to the physical and mental health of diverse rural low-income families.

Project Methods
A common qualitative protocol will be developed and tested for use by participating states that collect data. Participants will be recruited via a variety of methods to include announcements and flyers posted in public buildings or locations where low-income rural mothers are likely to frequent or congregate. Extension agents and other staff will be enlisted to inform and guide study outreach methods. Qualitative interviews will be conducted at a time and location convenient to the participant. Interviewers will be trained in the administration of and will use the commong protocol ti conduct the interview; interviews will be tape-recorded and transcribed. All multi-state interviews will be coded by a designated team according to a master coding schema. Studies utlizing the multi-state qualitative data will be performed by researchers from at least two participating states to produce research outputs such as peer-reviewed journal articles, conference presentations, and Extension educational materials.

Progress 10/24/16 to 09/30/19

Outputs
Target Audience:Community organizations were educated about the Rural Families Speak about Health multistate research project and the North Carolina-specific goals to reach African American mothers. Tabling and in-person outreach to organizations include: Let's Talk About It" suicide prevention Windsor (Bertie County, NC) community event, and the Albemarle Alliance for Children and Families (Bertie County, NC). In addition, mass outreach communications were sent to almost 90 community organizations and navigators in Eastern, NC with information about the Rural Families Speak research project as well as a request for assistance in recruiting participants. Responding community organizations included the Tyrrell County Department of Social Services, the Washington County Department of Social Services, Rural Health Group Inc. (Northampton County, NC), the North Carolina Department of Health and Human Services, the Hyde County Health Department, the Martin Tyrrell Washington District Health Department, and Metropolitan Community Health Services Inc. (Beaufort County, NC). Local Navigators that responded were from the Flatlands Insurance Group (Beaufort County, NC) and the NC Farm Bureau Mutual Insurance Company (Tyrrell County, NC) were also reached. These community organizations and Navigators received flyers and tear-off interest cards to display in their offices and distribute to their clients. Changes/Problems:One goal was to create a combined data set from NC1011 and NC1171 quantitative data to analyze changes across time. Upon engaging in this process it was discovered that there were an insufficient number of common variables to support combining these data sets. What opportunities for training and professional development has the project provided?Two Ph.D. and one Masters level graduate students received mentoring and training in reseach methods, community partnership development, and qualitative interview methods. How have the results been disseminated to communities of interest?Research results have been disseminated through conference presentations and juried publications. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? Community organizations were educated about the Rural Families Speak about Health multistate research project and the North Carolina-specific goals to reach African American mothers. Organizations reached include: Let's Talk About It" suicide prevention Windsor (Bertie County, NC) community event (September 9, 2017), the Albermarle Community organizations reached included the Choanoke Area Development Association of NC, Inc. and its Head Start sites in Bertie and Northampton Counties. Additionally, a mass communication was sent to almost 90 community organizations and navigators in Eastern, NC with information about the Rural Families Speak research project as well as a request for assistance in recruiting participants. Interviews were conducted with a study sample that included African American mothers age 18 and older who have or did have Obamacare or Affordable Health Care Act health insurance, and live in a rural Eastern North Carolina County (Bertie, Hyde, Northampton, Washington, Tyrrell). Participants shared about their experiences with the affordability and accessibility of health insurance coverage and healthcare, as well as their knowledge and use of cost-reduction programs related to the Affordable Care Act.

Publications

• Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Chandler, K., Barrett-Rivera, B., Sano, Y., Smith, S., & Bird C. (2019,November 20-23). A duel or a dance? Rural, low-income mothers experiences managing work and family time. Poster presented at the annual meeting of the National Council on Family Relations, Fort Worth, TX
• Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Bird, C. L., Chandler, K., Berry, A. & Barrett-Rivera, B. (2019, November 20-12). SNAP policies and the realities of rural working families: Implications for practitioners. Oral Presentation at the annual meeting of the National Council on Family Relations, Fort Worth, TX
• Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Chandler, K., Barrett-Rivera, B., Sano, Y., Smith, S., & Bird C. (July, 2018). A duel or a dance? Rural, low-income mothers experiences managing work and family time. Paper presented at the annual meeting of the Rural Sociological Society, Portland, OR
• Type: Journal Articles Status: Under Review Year Published: 2020 Citation: Bird, C. L., Chandler, K. D., Berry, A. A., & Barrett-Rivera, B. C. (in review). SNAP policies and the realities of rural working families: Implications for practitioners. Submitted to The Forum for Family and Consumer Issues.
• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Berry, A. & Bird, C., Mammen, S. & Burney, J. (March 2016). Rural families and health security. Family Economics and Resource Management Association, New Orleans, LA

Progress 10/01/17 to 09/30/18

Outputs
Target Audience:Community organizations were educated about the Rural Families Speak about Health multistate research project and the North Carolina-specific goals to reach African American mothers. Tabling and in-person outreach to organizations include: Let's Talk About It" suicide prevention Windsor (Bertie County, NC) community event, and the Albemarle Alliance for Children and Families (Bertie County, NC). In addition, mass outreach communications were sent to almost 90 community organizations and navigators in Eastern, NC with information about the Rural Families Speak research project as well as a request for assistance in recruiting participants. Responding community organizations included the Tyrrell County Department of Social Services, the Washington County Department of Social Services, Rural Health Group Inc. (Northampton County, NC), the North Carolina Department of Health and Human Services, the Hyde County Health Department, the Martin Tyrrell Washington District Health Department, and Metropolitan Community Health Services Inc. (Beaufort County, NC). Local Navigators that responded were from the Flatlands Insurance Group (Beaufort County, NC) and the NC Farm Bureau Mutual Insurance Company (Tyrrell County, NC) were also reached. These community organizations and Navigators received flyers and tear-off interest cards to display in their offices and distribute to their clients. Changes/Problems:The major changes in the period include modification of the study eligibility criteria, and two revisions to the IRB approval; one to allow Internet-based outreach methods and one to allow an honorarium for study participants. The original sampling criteria proved not to be a fit for North Carolina due to the fact that our state did not expand Medicaid. As a result, the sample as originally envisioned would not have accessed the Affordable Care Insurance program. Our original sampling criteria targeted mothers with children aged 12 or under. We conducted extensive outreach placing flyers in community locations and partnering with agencies and churches. However, the respondents with children aged 12 years and under all turned out to have Medicaid insurance rather than Affordable Care Act insurance. We also modified our IRB approval to conduct Google Outreach to target African American mothers in the targeted rural North Carolina North Eastern Counties. We conducted this outreach for two months without result. We connected with a Navigator community to seek assistance in identifying mothers who may be eligible. The Navigator arrived at the conclusion that mothers with young children would have Medicaid rather than Affordable Care Act insurance. Thus, we modified our sampling criteria to remove the criteria specifying young children. Originally, we did not have funds to offer an honorarium for participation in the research. Once funds were identified we modified our IRB and appropriate forms to allow for the honorarium. What opportunities for training and professional development has the project provided?Partnerships are being developed with local Navigator organizations to present project findings to inform their work in conducting outreach in North Carolina. How have the results been disseminated to communities of interest?Interviews are ongoing. We expect to hold a community forum to present a summary of their experiences. What do you plan to do during the next reporting period to accomplish the goals?We are continuing to conduct outreach to interview eligible participants. We received feedback from community partners (Navigators) that most women with young children would have Medicaid rather than Affordable Care Act insurance. Given that North Carolina did not expand Medicaid, Medicaid recipients would not qualify for the study. Therefore we have adjusted our eligibility requirements and continue to seek participants. We have connected also with a local Navigator Consortium and secured an invitation to present our research findings. We will be developing the presentation for the Navigator community.

Impacts
What was accomplished under these goals? (1) Experiences can differ based on geographic location, ethnicity, and social economic status. Qualitative interviews were conducted in rural North Carolina to better understand the experiences of low-income African American mothers. (2) Peer-reviewed publications were published and presentations at professional meetings were presented to disseminate findings to extend the body of knowledge available to family-serving professionals and policy makers regarding the experiences, barriers encountered, and concerns of rural low-income families as they seek health care and use Affordable Care Act insurance programs.

Publications

• Type: Journal Articles Status: Published Year Published: 2018 Citation: Mammen, S., Berry, A. A., Bird, C. L., Chandler, K. D. (2018). Rural low-income families quest for economic security: It takes more than a paycheck. Family Science Review, 22(1), 9-25.
• Type: Journal Articles Status: Under Review Year Published: 2019 Citation: Bird, C. L., Chandler, K. D., Berry, A. A., & Barrett-Rivera, B. C. (under review). Changing SNAP and work requirements: How the Farm Bill misses the mark for rural families. Submitted to The Forum for Family and Consumer Issues.
• Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Chandler, K., Barrett-Rivera, B., Sano, Y., Smith, S., & Bird C. (July, 2018). A duel or a dance? Rural, low-income mothers experiences managing work and family time. Paper presented at the annual meeting of the Rural Sociological Society conference, Portland, OR.

Progress 10/24/16 to 09/30/17

Outputs
Target Audience: Nothing Reported Changes/Problems:One goal was to create a combined data set from NC1011 and NC1171 quantitative data to analyze changes across time. Upon engaging in this process it was discovered that there were an insufficient number of common variables to support combining these data sets. What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest?A presentation was given at the Family Economics and Resource Management Association to reach family educators and practioners about rural families' access to heath care, rate of being insured, and ability to afford medicines. A journal article is currently under review for publication in a peer-reviewed journal for dissemination expected to reach family professionals. What do you plan to do during the next reporting period to accomplish the goals?In the next reporting period, I am on a leadership team coordinating an effort to develop a collection of peer-reviewed journal articles that incorporation Extension application. I am also seeking to collect data from African American women in North Carolina's rural areas.

Impacts
What was accomplished under these goals? A sub-committee developed a community protocol to investigate the experiences of health care providers when providing health care to patients using insurance under the Affordable Care Act. State PIs (North Carolina and others) used their personal networks to identify health care providers to pilot test the protocol. Means of deploying the survey was examined to determine the best point-of-contact within the medical practice to target. It was surmised that the medical doctor was unlikely to be the actual respondent. The survey questions underwent a second review and revision based on the piltot results and considerations of actual respondent within the healthcare/medical office practice.

Publications

• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Family Economics and Resource Management Association Biennial Meeting http://www.fermascholar.org/wp-content/uploads/2017/11/Rural-Families-and-Health-Security-Berry-Bird-Mammen-Burney.pdf
• Type: Journal Articles Status: Under Review Year Published: 2018 Citation: Mammen, S., Berry, A. A., Bird, C. L., & Davis, K. (in review). Rural, low-income families quest for economic security: It takes more than a paycheck. Family Sciences Review