1. After reading the article by Thomas et al., comment on where your research, or your research interests, fit into the generational framework for health disparities research. If your work is 1rst or 2nd generation, comment on how your work could lead in the future to 3rd or 4th generation work. If your work is 3rd or 4th generation, comment on what 1rst and 2nd generation work was necessary as a foundation for your current work (or current interests).
The field of general rural health disparities research has, to some extent, reached the level of third-generation work. First generation research in rural health established that there is a rural mortality penalty and continues with a focus on documenting the ways that rural health disparities are compounded by health determinants other than geography (Cossman et al., 2017; James et al., 2017). Second-generation rural health disparities research has done extensive work to identify their causes, often with a focus on social determinants, such as poverty, health insurance coverage, and healthcare accessibility/availability, to name a few. Third generation research in rural health disparities is largely focused on addressing social determinants,* for example, interventions to address access by increasing recruitment and retention of healthcare providers in rural areas, based on the understanding built in second-generation work. My area of research interest probably best fits into this third-generation, as one of my areas of interest is the actual health outcomes of rural healthcare workforce interventions.
This area may be moving toward fourth-generation research. Currently, research examining the health outcomes of rural healthcare workforce interventions is to my knowledge, non-existent. This is due in large part to the novelty of these interventions: we don’t yet have data on health outcomes, because we are still trying to understand if, and how, recruitment/retention interventions actually increase rural healthcare workforce. As interventions to increase the rural healthcare workforce are better developed and more widely/effectively implemented, we must accurately assess and document their impacts to health outcomes. We may find that health benefits are unevenly distributed among/across rural populations, as existing first- and second-generation rural health research has already shown. These compounded disparities point to the necessity of a multilevel approach to interventions that explicitly incorporate a public health critical race praxis.
*I would note that although the prevailing focus in rural health disparities causality and interventions research seems to be on social determinants, there is first-, second-, and third-generation work being done around individual health behaviors in rural populations.
Cossman, J., James, W., & Wolf, J. K. (2017). The differential effects of rural health care access on race-specific mortality. SSM Population Health, 3, 618-623.
James, C. V., Moonesinghe, R., Wilson-Frederick, S. M., Hall, J. E., Penman-Aguilar, A., & Bouye, K. (2017). Racial/ethnic health disparities among rural adults—United States, 2012–2015. MMWR Surveillance Summaries, 66(23). doi:10.15585/mmwr.ss6623a1
2. The barbershop hypertension intervention, while essentially a clinical services intervention operating at either the fence or safety-net level as described by Jones, has some engagement with the social determinants of health. Interventions like that described in the Gottleib article are designed to mitigate the impact of social determinants. How could you apply one of these two types of interventions to your area of research? Propose one or two interventions that engage with social determinants on some level.
Given that distance and transportation have been identified as factors contributing to rural health disparities, a possible intervention could screen patients to clinics for transportation needs. Borrowing inspiration from the Gottleib et al. article, those with identified transportation challenges could be randomized to receive information on local public transportation, information with transportation vouchers, or free (fairly ambitious here) individual pick-up and return transportation for medical appointments. It may be most relevant to identify a patient population with a chronic condition requiring frequent monitoring/follow-up, in order to be able to identify specific markers to measure as health outcomes. Per the Cliff Analogy, this would probably be a "net" intervention, and maybe not one that is particularly high on the cliff. A "fence" intervention aimed at the social determinants of health might be something like supporting existing and creating new home-health nurse visitation programs, meeting low-resource rural populations in their homes for public health and preventative care programs.