Selected Podcast
Health and Poverty of Rural Children
Nearly 1 in 5 children in the United States live in rural areas. Rural children experience health and health care disparities compared to their urban peers and represent a unique and vulnerable pediatric patient population. Important disparities exist in all-cause mortality, suicide, firearm-related unintentional injury, and obesity. In this episode, Dr. Jessica Bettenhausen discusses research into these disparities, their causes and potential actions to address them.
Featured Speaker:
Jessica Bettenhausen, MD, FAAP
Jessica Bettenhausen, MD, is an Associate Professor of Pediatrics at the University of Missouri-Kansas City and a Clinical Assistant Professor at The University of Kansas Medical Center. She is a practicing pediatric hospitalist and serves as the Research Director within the Division of Pediatric Hospital Medicine at Children’s Mercy Kansas City. Dr. Bettenhausen’s research aims to reduce health care disparities and to create a measurable improvement in health outcomes for children exposed to adverse social conditions. She is most interested in the role of partnerships between health care systems and community leaders and the effect of health care policy on improving child health equity. At a national level, she serves within the Executive Committee of the Academic Pediatric Association’s Health Policy Scholars Program and as a mentor within the Academic Pediatric Association’s Research Scholars Program Transcription:
Health and Poverty of Rural Children
Melanie Cole (Host): Welcome to Transformational Pediatrics with Children's Mercy, Kansas City.
I'm Melanie Cole. Joining me today is Dr. Jessica Bettenhausen. She's the research director in the division of pediatric hospital medicine at Children's Mercy, Kansas City. She's here to highlight health and poverty. Dr. Bettenhausen thank you so much for joining us today. And we've seen health disparities rise due to the unprecedented challenges the world in our country have been facing and rural communities have faced a Disproportionate health burden historically, but also in light of the impact of COVID. Can you tell us why you chose to study this topic of rural healthcare disparities? Describe the problem a little bit and some of the most significant disparities that you've outlined.
Dr Jessica Bettenhausen: Yes. Thank you, Melanie. And thank you for having me. As a pediatric hospitalist here at Children's Mercy in Kansas City, I take care of patients who are admitted to the hospital, but who don't require intensive care. And in this way, I see a wide variety of patients. And I also, I see patients that travel long, long distances to receive care at our hospital. As you know, children's Mercys in Kansas city and its location makes it geographically distant from other children's hospitals. And it means our catchment area is very, very large. And so in this way, it's not uncommon for me to see families who travel four or six or sometimes even eight hours, by car to get to our hospital.
It's also not uncommon for children to fly by a fixed wing aircraft from a rural emergency department to Children's Mercy, for hospitalization due to distance alone. In our area, children that are in non rural settings that have similar conditions to children that we see from rural settings can come by ambulance or even by car, if they're close enough, instead of having to fly in by fixed wing. And I started noticing these patterns early on in my career.
It made me want to learn more about the unique and challenging situations that rural families face during a hospitalization. It also made me wanna think more about what I could do to positively impact, the health and the wellbeing of, rural families and their children.
Melanie Cole (Host): And have you seen that this is affecting all aspects of their health as well? Not just in the acute setting, but also maybe chronic conditions and really all across the board?
Dr Jessica Bettenhausen: You bet. Nearly one in five kids live in rural areas and that population of children, in rural areas, they have discrete health have discrete healthcare, geographic and other socioeconomic differences. From just a general health perspective, rural children experience an all cause mortality rate that is about 25% higher than their non rural peers. and more specifically, the rates of infant mortality in SIDS or sudden infant death syndrome are about 50% higher. In addition to things that affect infants, the mortality rate from accidents, is nearly twice a national rate among rural children and death by suicide is 60% more prevalent.
An important consideration is that death from firearms, whether it's by suicide or by accident is a prominent aspect of mortality among rural kids. And for instance, a firearm is used in the act of suicide about two and a half times more often among rural adolescents. And I think that this highlights a remarkable disparity in both the mechanism and in the completion of suicide. And Melanie, you mentioned chronic conditions, rural children have similar rates of chronic conditions compared to children who don't live in rural areas.
The most common would include things like asthma or allergies or ADHD, or developmental delay, anxiety. Obesity is a particularly difficult problem among rural children. Rural children, experience obesity about 25% more often. And as you know, development of obesity and childhood leads to other lifelong conditions, including diabetes, hypertension, dyslipidemia, heart disease, and other chronic conditions.
Melanie Cole (Host): What an interesting topic we're discussing here today. Dr. Bettenhausen, as we've been talking about that, people from rural communities and receiving screenings, good healthcare. How then can healthcare providers work to break down some of these barriers and help make healthcare more accessible for those rural communities? What can be done to address those barriers to care? And thinking about long term solutions, how do you think the healthcare industry can be reformed to better serve underserved and rural patients?
Dr Jessica Bettenhausen: Access to care is a huge, burden, for rural families. But I think that there are a lot of things that we can do. Recent events, including COVID. Have allowed us to consider the capacity of telehealth more than ever before. And even before the widespread use of telehealth, there were healthcare innovations, like Project Echo that connected urban based subspecialist with rural primary care providers, and that helped better serve their complex patients. This connection between the urban subspecialists and the rural healthcare providers has been shown to reduce the need for care within emergency departments, as well as hospitalizations.
And for kids in particular, another intervention may include using schools, and creating rural school based clinics. So engaging with kids within schools could provide the opportunity to address chronic health conditions that would include pediatric mental health conditions. And if we consider using telehealth within schools, It may also improve the likelihood for broadband availability, which may not be available where a child lives. And even though telehealth is only one example of how innovations in healthcare, combined with expansion of broadband services, can improve access to healthcare. There are plenty of others, as well.
Melanie Cole (Host): So as you're talking about reducing some of those access and some of those barriers, working with people from rural communities can present unique opportunities for collaboration and creativity, as you mentioned about telehealth. In your personal experience, how have you seen this materialize at Children's Mercy, Kansas City? And what are your top recommendations for physicians to consider when they are treating children in rural communities?
Dr Jessica Bettenhausen: At Children's Mercy, we engage in telehealth consultations with individual families and also with rural healthcare providers. These relationships, help children to avoid having to use, emergency department services and be admitted to the hospital when their chronic conditions are poorly controlled. The other thing that doctors do at children's mercy, our subspecialists actually travel again by fixed wing to remote areas in Kansas and Missouri, to see patients in person, in areas that are closer to their home.
In terms of thinking about what physicians can do when they're taking care of patients from rural settings, I think there are a couple things that come to mind. The first is, considering, the social context of rurality and the challenges of access to care. As a hospitalist, this is most important to me when I'm discharging a patient and trying to think about what plans of care would be the most feasible for rural, patients and their families. The most safe, the most economical ways that families can seek care, outside of the hospital, as part of their treatment plan going forward.
But in terms of the social context, we also, as physicians, it's our duty to screen for social factors which may make healthcare more difficult to obtain. For instance, in rural areas, rural families are exposed to poverty at a greater rate. So approximately 20% of rural children live in poverty. And the counties that report more than 50% of their children in poverty, there are 41 counties in the United States that report that 50% of children are living in poverty, 39 of those 41 are in rural areas. The same thing happens with uninsurance. 48 of the 50 counties that report the highest rates of uninsurance are rural.
And so it's not surprising to realize that rural families often report travel related financial barriers, lack of appropriate transportation, concerns with lost wages or other financial stressors that are barriers, related to their ability to access healthcare. And so taking the social, context into consideration is as important in my opinion, as taking, into consideration the distance and the accessibility of healthcare, that rural families are able to receive.
Melanie Cole (Host): So as we wrap up and in terms of pediatric innovations, Dr. Bettenhausen and you just mentioned other portions of healthcare. Now there's also mental health, which we've seen an epidemic among our children in light of COVID and probably even before. So it's not only innovation in terms of new technology, devices, telehealth, that sort of thing, but an innovation as a philosophical shift right from providers that we're working in silos to now working together around the state.
As we wrap up, please tell other providers what you would like them to know about disseminating this information between providers even in light of public health emergencies, like COVID 19. What else would you like to add to this conversation as a key takeaway for other providers about these rural healthcare disparities?
Dr Jessica Bettenhausen: I think the key takeaway is that we need to work together. Rural children are under resourced, they're also under researched. As a research director. I realize how little is written about the rural condition and how that effects the health of children in rural areas. I do believe that the solutions. lie in this partnership and they also lie in areas of policy change and research. So from a healthcare perspective, thinking about how to partner urban and rural subspecialists and generalists to provide needed healthcare, especially mental healthcare to children is very, very, very important.
But from the perspective of policy, I think it's really important that we think about things like payment purity for telehealth. Which generally means that telehealth visits would count the same or be reimbursed the same as in person visits. And thinking innovatively about providing telehealth, you know, mental health services, to our pediatric patients, I think is a really important aspect to consider. But from a research perspective, even though rural kids have unique disadvantages, like I mentioned, there's little research that includes the rural population as a focus.
And so thinking about partnerships between policy makers. Researchers and communities to really study rural populations and study them longitudinally so that we can better understand both the short and the long term effects of rural is important. I think in this way, these partnerships can also, study interventions and learn which interventions work the best for children who live in rural areas. We have to concentrate on identifying health related challenges for the rural population as a whole. But also the health related challenges of underrepresented minorities within rural populations, which is even less studied, than rural populations as a whole.
Melanie Cole (Host): What great points you've made here. And it's such an important topic we've discussed. Thank you so much, Dr. Bettenhausen for joining us today. And to refer your patient or for more information, you can visit childrensmercy.org to get connected with one of our providers. This has been Transformational Pediatrics with Children's Mercy, Kansas City. I'm Melanie Cole.
Health and Poverty of Rural Children
Melanie Cole (Host): Welcome to Transformational Pediatrics with Children's Mercy, Kansas City.
I'm Melanie Cole. Joining me today is Dr. Jessica Bettenhausen. She's the research director in the division of pediatric hospital medicine at Children's Mercy, Kansas City. She's here to highlight health and poverty. Dr. Bettenhausen thank you so much for joining us today. And we've seen health disparities rise due to the unprecedented challenges the world in our country have been facing and rural communities have faced a Disproportionate health burden historically, but also in light of the impact of COVID. Can you tell us why you chose to study this topic of rural healthcare disparities? Describe the problem a little bit and some of the most significant disparities that you've outlined.
Dr Jessica Bettenhausen: Yes. Thank you, Melanie. And thank you for having me. As a pediatric hospitalist here at Children's Mercy in Kansas City, I take care of patients who are admitted to the hospital, but who don't require intensive care. And in this way, I see a wide variety of patients. And I also, I see patients that travel long, long distances to receive care at our hospital. As you know, children's Mercys in Kansas city and its location makes it geographically distant from other children's hospitals. And it means our catchment area is very, very large. And so in this way, it's not uncommon for me to see families who travel four or six or sometimes even eight hours, by car to get to our hospital.
It's also not uncommon for children to fly by a fixed wing aircraft from a rural emergency department to Children's Mercy, for hospitalization due to distance alone. In our area, children that are in non rural settings that have similar conditions to children that we see from rural settings can come by ambulance or even by car, if they're close enough, instead of having to fly in by fixed wing. And I started noticing these patterns early on in my career.
It made me want to learn more about the unique and challenging situations that rural families face during a hospitalization. It also made me wanna think more about what I could do to positively impact, the health and the wellbeing of, rural families and their children.
Melanie Cole (Host): And have you seen that this is affecting all aspects of their health as well? Not just in the acute setting, but also maybe chronic conditions and really all across the board?
Dr Jessica Bettenhausen: You bet. Nearly one in five kids live in rural areas and that population of children, in rural areas, they have discrete health have discrete healthcare, geographic and other socioeconomic differences. From just a general health perspective, rural children experience an all cause mortality rate that is about 25% higher than their non rural peers. and more specifically, the rates of infant mortality in SIDS or sudden infant death syndrome are about 50% higher. In addition to things that affect infants, the mortality rate from accidents, is nearly twice a national rate among rural children and death by suicide is 60% more prevalent.
An important consideration is that death from firearms, whether it's by suicide or by accident is a prominent aspect of mortality among rural kids. And for instance, a firearm is used in the act of suicide about two and a half times more often among rural adolescents. And I think that this highlights a remarkable disparity in both the mechanism and in the completion of suicide. And Melanie, you mentioned chronic conditions, rural children have similar rates of chronic conditions compared to children who don't live in rural areas.
The most common would include things like asthma or allergies or ADHD, or developmental delay, anxiety. Obesity is a particularly difficult problem among rural children. Rural children, experience obesity about 25% more often. And as you know, development of obesity and childhood leads to other lifelong conditions, including diabetes, hypertension, dyslipidemia, heart disease, and other chronic conditions.
Melanie Cole (Host): What an interesting topic we're discussing here today. Dr. Bettenhausen, as we've been talking about that, people from rural communities and receiving screenings, good healthcare. How then can healthcare providers work to break down some of these barriers and help make healthcare more accessible for those rural communities? What can be done to address those barriers to care? And thinking about long term solutions, how do you think the healthcare industry can be reformed to better serve underserved and rural patients?
Dr Jessica Bettenhausen: Access to care is a huge, burden, for rural families. But I think that there are a lot of things that we can do. Recent events, including COVID. Have allowed us to consider the capacity of telehealth more than ever before. And even before the widespread use of telehealth, there were healthcare innovations, like Project Echo that connected urban based subspecialist with rural primary care providers, and that helped better serve their complex patients. This connection between the urban subspecialists and the rural healthcare providers has been shown to reduce the need for care within emergency departments, as well as hospitalizations.
And for kids in particular, another intervention may include using schools, and creating rural school based clinics. So engaging with kids within schools could provide the opportunity to address chronic health conditions that would include pediatric mental health conditions. And if we consider using telehealth within schools, It may also improve the likelihood for broadband availability, which may not be available where a child lives. And even though telehealth is only one example of how innovations in healthcare, combined with expansion of broadband services, can improve access to healthcare. There are plenty of others, as well.
Melanie Cole (Host): So as you're talking about reducing some of those access and some of those barriers, working with people from rural communities can present unique opportunities for collaboration and creativity, as you mentioned about telehealth. In your personal experience, how have you seen this materialize at Children's Mercy, Kansas City? And what are your top recommendations for physicians to consider when they are treating children in rural communities?
Dr Jessica Bettenhausen: At Children's Mercy, we engage in telehealth consultations with individual families and also with rural healthcare providers. These relationships, help children to avoid having to use, emergency department services and be admitted to the hospital when their chronic conditions are poorly controlled. The other thing that doctors do at children's mercy, our subspecialists actually travel again by fixed wing to remote areas in Kansas and Missouri, to see patients in person, in areas that are closer to their home.
In terms of thinking about what physicians can do when they're taking care of patients from rural settings, I think there are a couple things that come to mind. The first is, considering, the social context of rurality and the challenges of access to care. As a hospitalist, this is most important to me when I'm discharging a patient and trying to think about what plans of care would be the most feasible for rural, patients and their families. The most safe, the most economical ways that families can seek care, outside of the hospital, as part of their treatment plan going forward.
But in terms of the social context, we also, as physicians, it's our duty to screen for social factors which may make healthcare more difficult to obtain. For instance, in rural areas, rural families are exposed to poverty at a greater rate. So approximately 20% of rural children live in poverty. And the counties that report more than 50% of their children in poverty, there are 41 counties in the United States that report that 50% of children are living in poverty, 39 of those 41 are in rural areas. The same thing happens with uninsurance. 48 of the 50 counties that report the highest rates of uninsurance are rural.
And so it's not surprising to realize that rural families often report travel related financial barriers, lack of appropriate transportation, concerns with lost wages or other financial stressors that are barriers, related to their ability to access healthcare. And so taking the social, context into consideration is as important in my opinion, as taking, into consideration the distance and the accessibility of healthcare, that rural families are able to receive.
Melanie Cole (Host): So as we wrap up and in terms of pediatric innovations, Dr. Bettenhausen and you just mentioned other portions of healthcare. Now there's also mental health, which we've seen an epidemic among our children in light of COVID and probably even before. So it's not only innovation in terms of new technology, devices, telehealth, that sort of thing, but an innovation as a philosophical shift right from providers that we're working in silos to now working together around the state.
As we wrap up, please tell other providers what you would like them to know about disseminating this information between providers even in light of public health emergencies, like COVID 19. What else would you like to add to this conversation as a key takeaway for other providers about these rural healthcare disparities?
Dr Jessica Bettenhausen: I think the key takeaway is that we need to work together. Rural children are under resourced, they're also under researched. As a research director. I realize how little is written about the rural condition and how that effects the health of children in rural areas. I do believe that the solutions. lie in this partnership and they also lie in areas of policy change and research. So from a healthcare perspective, thinking about how to partner urban and rural subspecialists and generalists to provide needed healthcare, especially mental healthcare to children is very, very, very important.
But from the perspective of policy, I think it's really important that we think about things like payment purity for telehealth. Which generally means that telehealth visits would count the same or be reimbursed the same as in person visits. And thinking innovatively about providing telehealth, you know, mental health services, to our pediatric patients, I think is a really important aspect to consider. But from a research perspective, even though rural kids have unique disadvantages, like I mentioned, there's little research that includes the rural population as a focus.
And so thinking about partnerships between policy makers. Researchers and communities to really study rural populations and study them longitudinally so that we can better understand both the short and the long term effects of rural is important. I think in this way, these partnerships can also, study interventions and learn which interventions work the best for children who live in rural areas. We have to concentrate on identifying health related challenges for the rural population as a whole. But also the health related challenges of underrepresented minorities within rural populations, which is even less studied, than rural populations as a whole.
Melanie Cole (Host): What great points you've made here. And it's such an important topic we've discussed. Thank you so much, Dr. Bettenhausen for joining us today. And to refer your patient or for more information, you can visit childrensmercy.org to get connected with one of our providers. This has been Transformational Pediatrics with Children's Mercy, Kansas City. I'm Melanie Cole.