Expert Commentary

3 tips for reporting on rural health

“I think there's an under appreciation of the nuance of ‘rural,’” said Mark Holmes, who directs the NC Rural Health Research and Policy Analysis Center.

rural scene

Mark Holmes is a professor in the department of health policy and management in the University of North Carolina Gillings School of Global Public Health and director of the North Carolina Rural Health Research and Policy Analysis Center.

At the North Carolina Rural Health Research and Policy Analysis Center, Holmes studies rural hospital closures across the country, as well as the effects of Medicare and Medicaid on rural populations and health care providers.

Earlier this month, Holmes participated in a panel on rural health at Health Journalism 2019, the annual conference of the Association of Health Care Journalists (AHCJ). Beforehand, we took the opportunity to sit down with him and ask about his tips for reporting on rural health. Below are three of the key takeaways from our conversation.

Tip #1: Be specific about what you mean when you say “rural.” Different regions face different issues.

The term “rural” can be used as a monolithic catchall for vast and diverse areas of the country: for example, the U.S. Census defines rural as “territory, population, and housing units not classified as urban.”

“I think there’s an under appreciation of the nuance of ‘rural,’ in that rural North Carolina is very different from rural Wyoming, and we tend to lump them all together,” Holmes said. “I think certainly people have been talking about the difference in the demographics –the rural South versus rural Midwest — but also I think the notion of isolation, geographic isolation, can be quite varied.” In other words, be specific about what you mean when you’re talking about rural: Is the area isolated? Far from a hospital? Sparsely populated?

The upshot: It’s important to know the issues facing the various rural regions in the United States.

With that in mind, we asked Holmes to provide, to the extent that he was comfortable, a categorization of many of the rural regions across the U.S. and the key health issues for local journalists to keep an eye on. Here are his suggestions:

Northeast New England (categorized by Holmes as consisting primarily of Maine, northern Vermont and New Hamsphire, and western Massachusetts):  Holmes said the key concerns in the rural Northeast are the opioid epidemic and an aging population.

“A lot of New England is not terribly far from other large health care systems,” Holmes qualified.

South (including the Mississippi Delta, Appalachia and the ‘Stroke Belt’): Key health-related issues include racial disparities, poverty, homicide, rural hospital closures and rural hospital financial distress – i.e., hospitals struggling to cover their costs.

Upper Midwest (Minnesota, Wisconsin, Michigan, North and South Dakota, Iowa): “From a mortality standpoint, the Midwest tends to be some of our healthiest regions — not just rural, but urban as well,” Holmes said.  However, the upper Midwest is “generally more isolated than we see in the South. You can get into a frontier area in the Midwest pretty quickly.” Holmes explained that the isolation in some parts of the Midwest means rural residents might not have ready access to hospitals.

Mountains West: Suicide – particularly suicide involving firearms– is a major issue in the rural, mountainous West, he said.

Rural California (particularly the Central Valley and the southern border region): Holmes said this region faces “its own acute or more specific challenges particularly associated with migrant farm workers.”

Alaska: Geographic isolation creates health-related challenges here.

Hawaii: The state is unique, Holmes said, in that it is geographically isolated, but each island has its own hospital, so access to health care is not impeded by its isolation. The issue then becomes the economic and operational challenges of maintaining hospitals that are underused. “Those are some of the most underused hospitals,” Holmes said. “You’ll have a hospital on an island that might have, like, one patient a week. But when you need it, they’re there.”

Tip #2: Don’t just focus on problems; also cover successful community-based solutions in rural America.

“I think the biggest [issue with coverage of rural health] is every story about rural is despondent, despair,” Holmes said. “I think some really groundbreaking approaches have been developed in these kinds of communities.”

Holmes described his own experience growing up in rural Michigan. After a spate of teen deaths in car accidents, Holmes said the community came to a realization: “Now we have a crisis. And so the whole community rallies around each other and sort of figures out what we’re going to do about it.

“You can see faster action, I think, in rural communities, because at the coffee shop you can get the three people that matter together on a Thursday afternoon without a lot of the hassles you might see in larger communities.

“Those are harder stories to find, but I think they’re really interesting, because as researchers we pound the table and say you need to use evidence-based programs, and draw from what we know works,” he says. “But innovation often happens in rural communities where they say, you know what, we got this thing over here and this thing over here and in using our assets in an innovative area, or in an innovative manner, we can try something new. Sometimes it works, sometimes it doesn’t.”

Tip #3: Understand that health care touches other newsroom beats, and other beats touch health care. Consider, for example, its connections with economic development.

“Rural areas face a wide variety of decisions about what their economic development strategy will be — keeping people and recruiting people,” he said. “Having a viable, strong health care system, it is really important, and of course it goes the other way as well — the economy improves the health care system.

“My bread and butter is rural hospital closures,” Holmes said. But he and his team also research rural hospital openings. “We found two in one year and looked at the stories, and both of the justifications were highly dependent on: we want to create a place where people want to live, because having the hospital here makes it worth it,” he said.

Additional resources

Holmes recommended the following resources for journalists looking to learn more about rural health:

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