Antonina Storniolo1, Lisa Qiu1, Kelley Gorsuch1, Bryan Greene1, Codey Pedersen1, Lauren Wolfe1, Raquel Moore MPH
PNWMSRJ. Published online Oct 5th, 2020.Abstract
Introduction: When compared to surrounding communities, the rural town of Sweet Home, Oregon has high rates of unmet health care needs. Concerns outlined in previous studies include primary care capacity ratio, mental health care, dental health care, and preventable hospitalizations. 4 While quantitative measures are often used to measure unmet health care need, the goal of this qualitative study was to use participatory research methods to better understand needs through focus groups with community members. Methods: This study consisted of a series of four focus groups with the goal of eliciting community member perception of health care strengths and barriers. The study included twenty participants who were long-term Sweet Home residents over the age of 18. Results: Participants reported community strengths of high levels of engagement and a strong desire to improve health outcomes. Participants reported frustration with high primary care provider turnover and lack of after-hours health care. While there was no singular conclusion about the greatest health concerns in the community, participants cited concerns about transportation, poor nutrition, drug and alcohol use, homelessness, mental health issues and an aging population. Conclusion: By engaging in participatory research, this study allowed for a deeper understanding of community concerns and provided possible solutions to improve health care access and delivery. Understanding community perceptions of health needs may be useful to guide future health care initiatives in this community.
Introduction
Americans living in rural communities of the United States receive disproportionately worse health care than those living in urban settings.1 Residents of rural areas tend to have higher smoking and obesity rates, lower amounts of physical activity and less access to medical insurance.2 Consequently, rural areas report higher mortality rates and overall less healthy individuals, as compared to urban cities.3
The Oregon Office of Rural Health published the Areas of Unmet Health Care Need Report (AUHCN) in 2017 that evaluated unmet health care needs in Oregon’s 130 primary care service areas.4 Each area receives a score from 0 to 90, with 90 being the best and 0 being the worst score. When compared to its surrounding areas, the community of Sweet Home, Oregon, was ranked as having higher than average amount of unmet need, specifically in the areas of primary care capacity ratio, mental health care, dental health care, and preventable hospitalizations. The mean score for Oregon was 41.1, with Sweet Home scoring 34.4 Sweet Home also scored below the mean for its geographic area, rural (without frontier), which had a mean score of 37.9. With an estimated population of 9,9775 and its location 15 miles from the closest community hospital, Sweet Home is an ideal representative of rural Oregon populations. Like many American communities, the 1980s brought a significant population and industrial decline to the region. Due to increased competition, logging regulations, and economic fluctuations of the time, Sweet Home experienced closures of its sawmills and logging operations that greatly impacted the community’s identity.6
After identifying Sweet Home as an area with high unmet health care need, researchers wanted to better understand the community’s health care resources, weaknesses and strengths. Participatory community research is a model that can be useful to help understand both structural and personal barriers that patients encounter while utilizing health care resources. One such model, Community Health Improvement Partnership (CHIP) suggests that including community members’ feedback when determining unmet health care needs can benefit the overall health of the community.7 Researchers determined that focus groups would be an effective strategy to better understand community perspectives and provide insight into the high level of unmet health care need in Sweet Home.
Materials and Methods
Study Design
The research team began by collaborating with a local community leader in Sweet Home to create focus groups. With the help of the community leader, participants within the community were selected based on long-term residency in Sweet Home. Participants represented both elected officials and community members. None of the participants were directly involved in health care delivery. Four focus groups were conducted. The first focus group consisted of seven elected officials. The remaining three focus groups consisted of participants who represented health care utilizers. A total of 20 participants were included in this study. Focus groups were conducted at the Sweet Home School District office on April 19th, May 3rd, May 9th and May 23rd 2018. Each group was facilitated by two medical student researchers and a third researcher who recorded participants’ nonverbal cues. Nonverbal cues were used to better understand emotions and reactions to questions. Afterwards, each focus group was recorded and transcribed verbatim. Transcriptions are available upon request to the author.
Inclusion and exclusion criteria
In order to participate in the study, individuals confirmed they spoke English, were over the age of 18 and currently lived in the Sweet Home area.
Focus Group Guidelines:
The focus groups took place at the Sweet Home School District offices. Before beginning the focus group interview, one facilitator verbally explained the goals of the focus group and read the verbal consent dialogue. The facilitators allowed time for questions before proceeding. After this, participants conversed freely, with guidance from the facilitators. The facilitators used the following questions to guide the group:
- What local health resources are you aware of?
- What do you think is the biggest health concern for Sweet Home residents?
- What additional resources do you think would be most beneficial to improve the health of Sweet Home residents?
Results
Study Demographic
A total of 20 participants were included in this study. The ages of participants ranged from 42 to 74 years old. Six participants identified as female and 14 identified as male. Seven participants reported that they were college graduates, nine reported that they had attended “some college”, three reported “other,” and one declined to report their education level.
Focus Group Discussions
In this study, three overarching questions were proposed and discussed among participants. The focus group recordings were reviewed and transcribed after the meetings. From these transcriptions, researchers identified overarching themes that were discussed in more than one focus group to be included in the results. Reviewing the four focus groups, the overarching themes were fairly congruent. An effort was made to preserve dissenting and outlying opinions as well. Using these themes, researchers summarized or quoted participants’ commentary.
Question 1: What resources exist for Sweet Home residents?
When describing resources that exist in the community, a common theme was that the community itself is a vital resource and “when the community decides that something is going to happen…it happens.” In addition, participants noted that the annual Community Health Fair is an important resource that provides essential medical, dental, and health care services for hundreds of attendees. Participants also reported that the Sweet Home Family Medicine (SHFM) clinic plays a crucial role in community health but is the only primary health care option available and does not fully meet community needs due to limited hours of operation, rotating primary care physicians and difficulty obtaining an appointment. Participants reported resources that include the Boys and Girls Club, Head Start, Sweet Home Emergency Ministry Food Bank, Meals on Wheels and church groups that are available to serve community needs.
Question 2: What do you think is the biggest health concern for Sweet Home residents?
Transportation to care facilities
Many participants brought up the difficulty of physically getting to the care facilities in Sweet Home. Specifically, participants noted that many Sweet Home residents do not have reliable transportation options.
Poor Nutrition
Multiple participants identified poor nutrition as a source of chronic disease. Several participants believed that a large percentage of the population under the age of 18 receives meals through the free and reduced lunch program. Members of the elected officials focus group verified this report.
Drug and Alcohol usage
Drug and alcohol use and addiction were brought up in each of the focus groups. One participant noted that “I don’t think it’s worse than any other small town”, but others identified it as a larger problem. One participant reported having trouble finding employees for entry level jobs due to their inability to pass a drug test. Multiple participants identified that there are few treatment options in the area for people struggling with addiction.
Homelessness
Homelessness was identified by several participants as a community concern. They reported that there are not many resources available to the homeless population in Sweet Home. One participant reported that there were several families who were no longer able to afford rent and were forced to live out of their cars. Another participant stated that many students in the high school were homeless.
Mental Health
Participants were aware of people suffering from issues including depression, anxiety, addiction and PTSD. Several participants believed that the lack of mental health resources contributed to a substance abuse problem.
Aging population
Several participants pointed out that Sweet Home has an increasing retired population and a declining population of middle-aged people in the workforce. Participants largely agreed that the average age of a resident in Sweet Home is increasing and that this population shift requires unique services.
Question 3: What additional resources do you think would be most beneficial to improve the health of Sweet Home residents?
Increased Primary Care Providers/Urgent Care resources
Participants unanimously reported a desire to have more primary care providers (PCPs) in the area and less turnover of existing physicians. While some people noted no difficulty in retaining a PCP, one participant highlighted that in eight years, he has had four different PCPs. In all the focus groups, participants mentioned the community’s desire to build a new urgent care or expand the current urgent care to include weekend hours. Participants stated that they believed if more providers were available to work in Sweet Home, the community would be able to fundraise money to buy land and build the facility.
Frustration with Existing Resources
A relatively small, but outspoken, group of participants expressed frustration with Samaritan Health Services (SHS). One participant told us that they have attempted to talk to SHS about the lack of hours and services but has not seen any action, “we’ve had these talks with Samaritan and we haven’t gotten anywhere with that” further stating that “it’s the perception that because we are Sweet Home, out here on the end, not quite as important.”
Preventative/Community Health events
Participants emphasized the need for preventative programs, both at schools and in the community. One participant noted, “…that might be the model we jump to… a healthy community program.” Many people believed that the health fair is an effective opportunity to reach community members who rarely leave their homes and that “there was at least one instance where when screening [at the health fair] saved somebody’s life.”
Mentorship
Participants consistently addressed the need for mentorship for teenagers and children in the community. Many participants expressed the desire for medical students to serve as mentors for children in their community by speaking to children about career goals and healthy living. One participant noted, “There are kids here just looking for heroes.”
Discussion
This study attempts to further understand community perceptions of health in Sweet Home through the use of focus groups. When starting this study, researchers had an understanding of areas of unmet health care need in Sweet Home, based on quantitative data, which included primary care capacity ratio, mental health care, dental health care, and preventable hospitalizations. Researchers found that participant’s experiences supported these statistical findings but also illuminated unique challenges and strengths. It was apparent that lack of health care resources available to the residents has resulted in a fraught relationship between residents and the local health care organization. The limited care options available to residents had created a perception that the organization was not taking an active role in investing more medical opportunities in the town. While there was no singular conclusion about the greatest health concerns in the community, participants cited concerns about transportation, poor nutrition, drug and alcohol use, homelessness, mental health issues and an aging population. For the most part, there was congruency between the focus group that included elected officials and the ones that represented community members. There was some disagreement on the extent of the issue that substance abuse presents, which could be an area of future study. Participants recognized that many of these concerns could be addressed through increased preventative health strategies. Importantly, participants consistently reiterated the strength of their community to overcome challenges and to band together to create opportunities.
While this study is specific to the rural community of Sweet Home, this participatory research is an example of the value of coming directly to community members to assess their wants and needs prior to the implementation of projects. In this case, many community concerns were in line with prior reports on health care needs, but several had not been mentioned in prior literature about Sweet Home. For example, the AUHCN did not identify travel time to PCP as a concern, but residents consistently brought this up as a barrier to health care access. This study demonstrates not only specific, actionable items for improvement in unmet health care needs but also serves as an example of the importance of narrative, qualitative studies in addition to quantitative research.
Limitations
As with all qualitative studies, our findings can only be generalized to a certain extent. Other limitations of this study include the small sample size (20 participants) and a skewed age range (all participants were over the age of 42). There was also a sex ratio favoring males (about 2:1). Another limitation is that we had a lead person dictate whom in the community to involve in the focus groups. While this gave us a source within the community and built trust between researchers and participants, it may have contributed to selection bias. If this study were continued, researchers would seek a larger sample and more randomized group.
Conclusion
The barriers to ensuring that community health needs are met are complex and cannot be described by any single factor. As detailed in this research, Sweet Home participants asserted community strengths, including a strong sense of community pride and motivation to improve health outcomes. They also delineated challenges, such as the need for increased providers, and concerns over preventative care gaps. This study highlighted the importance of utilizing community voices to guide implementation of projects. This qualitative research can be compared to quantitative studies to determine areas of health care need and find solutions that benefit the community.
Acknowledgments
We thank Diana Lacey for facilitating this collaborative project among Western University of Health Sciences of the Pacific – Northwest campus, Samaritan Health Services, and the community representatives of Sweet Home, Oregon.
References
- Kirby JB, Muhuri P. Insurance and Access to Care in Urban and Rural Areas, 2014-2015. Statistical Brief (Medical Expenditure Panel Survey (US)). Agency for Healthcare Research and Quality (US); 2018.
- Williams D, Jr., Holmes M. Rural Health Care Costs: Are They Higher and Why Might They Differ from Urban Health Care Costs? N C Med J. Jan-Feb 2018;79(1):51-55. doi:10.18043/ncm.79.1.51
- James WL. All Rural Places Are Not Created Equal: Revisiting the Rural Mortality Penalty in the United States. American Journal of Public Health. 2014;104(11):2122-2129. doi:10.2105/ajph.2014.301989
- Oregon Areas of Unmet Health Care Need Report. 2017:33.
- Quickfacts Sweet Home City Oregon. United States Census Bureau. https://www.census.gov/quickfacts/fact/table/sweethomecityoregon/PST040219
- Sweet Home Oregon History. Sweet Home City Hall. https://www.sweethomeor.gov/executive/page/history
- Young-Lorion J, Davis MM, Kirks N, et al. Rural Oregon community perspectives: introducing community-based participatory research into a community health coalition. Prog Community Health Partnersh. 2013 2013;7(3):313-322. doi:10.1353/cpr.2013.0032
Article information:
Published Online: Oct 5th, 2020.
IRB Approval: This study was approved by the Samaritan Health Services Institution Review Board (IRB). IRB number 18-019.
Conflict of Interest Declaration: The authors have no conflicts of interest to disclose.
Funding Source/Disclosure: Sweet Home school district office was used to collect data.