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‘Older, sicker, poorer’ — How not to write about rural and more from the Rural Health Journalism Workshop

I’ve just returned from a trip to Denver, Colorado for the Association of Health Care Journalists’ 2019 Rural Health Journalism Workshop dedicated to the health issues of rural America and how journalists can best write about them. It was a full day of presentations by health care and policy experts that left journalists not only with a better understanding of rural health issues, but also several new story ideas. Here are five of my key takeaways.

1. There are lots of definitions of rural.

“Rural is always defined as not urban,” said Michael Meit, co-director of the  NORC Walsh Center for Rural Health Analysis, pointing out how this very broad definition is problematic. It sounds simple enough, except it turns out there are over 70 federal and state definitions of rural.

That’s why the Rural Health Information Hub created a tool to “determine whether your specific location is considered rural based on various definitions of rural, including definitions that are used as eligibility criteria for federal programs.” The tool — called Am I Rural? — allows you to enter an address and receive a report on program eligibility and how your location is defined, as well as if it falls in a health professional shortage or medically-underserved area.

Shawnda Schroeder, principal investigator at Rural Health Research Gateway and research assistant professor at the University of North Dakota’s Center for Rural Health, said it is especially important to know which definition of rural researchers are using when creating data sets, since this would greatly affect data interpretation.

2. Be aware of how you write about rural.

Speaking of data, there are several rural data challenges, including small numbers, data suppression, and inconsistent/under-reporting.  

“The data in rural areas can lead to very negative reporting,” Meit warned. He shared a series of headlines that he said would make readers think everyone in Appalachia was on disability or dealing with addiction.

“If this is the narrative that our urban counterparts are getting, they’re never going to make that investment,” Meit said, pointing to a real consequence of these depictions.

In response, NORC partnered with the Robert Wood Johnson Foundation (RWJF) and others to look at how to leverage assets, including community and cultural assets of rural communities, for better outcomes. One of the resulting reports, Exploring Strategies to Improve Health and Equity in Rural Communities, can be found here.

“This whole conceptualization of rural as older, sicker, poorer drives us absolutely insane,” Meit said.

Schroeder agreed, saying she encourages journalists to think and write beyond rural stereotypes.

“Rural communities are not all the same … especially when it comes to solutions,” she said.

3. Combatting the opioid crisis remains a battle across the country.

While I had previous experience reporting on the opioid crisis in North Carolina, it was eye-opening to see another state’s experiences and responses. At the conference, I learned that, as recently as five years ago, Colorado ranked second in the country in the misuse of prescription drugs.

“If we cut off all these people from their opioids, what do we think is going to happen?” asked Marc Condojani, director of adult treatment and recovery at the Colorado Department of Human Services.

Recognizing the issue as a health care-generated crisis, Condojani and his team began looking at prescribing practices.

“This data is going to be predictive of where your problems are,” he said. This research led to a win with the legislature last year, with Colorado passing a bill to limit opioid prescriptions to opioid-naive patients (patients who had not been prescribed opioids before).

Now, the Department of Human Services is continuing with a three-step plan:

  1. Decrease the number of people dependent on opioids (e.g., with the bill limiting prescriptions)
  2. Decrease loss of life (e.g., through the administration of Narcan to reverse overdoses)
  3. Expand access to treatment

Colorado is also targeting Medication Assisted Treatment (MAT) by looking at MAT deserts, expanding MAT services in jails, providing mobile MAT units, and providing peer navigators that help those in recovery get connected to MAT.

Regarding the idea of marijuana for pain (with marijuana being legalized in Colorado) and as a way to get people off of opioids, Condojani said skeptically, “I am research-driven. Show me the studies. Let me see it replicated.”

4. There’s a link between asthma and chronic absenteeism.

In part of a presentation on lung health in vulnerable populations, Lisa Cicutto, director of community outreach and research at National Jewish Health, shared data on asthma that stood out to me. EducationNC did a deep dive on the issue of chronic absenteeism last year, and Cicutto shared information on the connection between asthma and students missing 10 or more days of school.

These students also tended to have higher dropout rates, she said.

There were several factors contributing to higher exacerbation of asthma in rural areas, including smoking. Cicutto pointed out that smoking is often rooted in the social environment of rural areas, that those living in rural areas start smoking at younger ages and smoke more — and are also more likely to be exposed to second-hand smoke.

Meanwhile, tobacco marketers target rural youth while this same demographic is less likely to hear anti-smoking campaigns. Cicutto said this also applied to e-cigarettes.

“We’re just seeing it’s so tremendous in terms of the uptake of it. … They have absolutely no understanding of what they’re doing, and they think it’s safe,” she said, adding that there is data that even non-smokers who use e-cigarettes are more likely to use combustible cigarettes later.

There are also environmental issues that can lead to higher rates of asthma in rural areas. In Colorado, this includes dust storms. Cicutto said that after major dust storms, hospitals would see an uptick in the number of admissions for children with asthma.

In more severe situations, some living in rural areas of Colorado had no access to services like plumbing and heat. This meant that these homes relied on burning dung and garbage for “supplemental heat” — because using wood would be too expensive to afford. Burning these substances in the home would also lead to exacerbation of asthma.

Cicutto summarized the implication of students missing school due to asthma-related issues on one slide, writing, “Rural populations are constantly attempting to manage multiple risk factors in children that lead to health and educational disparities that become compounded inequities in adulthood.”

5. Sensitivity is required when writing about suicide.

The topic of “deaths of despair” (like suicide, liver disease, and overdose) came up in several instances throughout the conference, with one presentation fully dedicated to the issue among one specific population: veterans.

Nazanin Bahraini, director of education at Veterans Affairs Rocky Mountain Mental Illness Research Education and Clinical Center, asked the audience how many veterans they thought lived in the United States. Guesses came in: 1 million, 3 million, 5 million.

“Twenty million,” she said.

A larger proportion of these veterans live in rural areas and rural veterans have a 20% increased risk of suicide after accounting for access to care, demographics, and diagnoses such as depression, Bahraini explained.

However Bahraini’s key message, along with co-presenter Charles Smith, regional administrator at SAMHSA, was that suicide is preventable.

The U.S. Department of Veterans Affairs released a report, titled National Strategy for Preventing Veteran Suicide 2018-2028, that is dedicated to prevention solutions in this population.

Panel moderator Cheryl Platzman Weinstock, an independent journalist, also addressed the audience with tips on how to write about suicide with sensitivity and key details that need to be left out of stories:

  • Don’t include suicide in the crime section of news.
  • Don’t include details of how the person carried out the suicide.
  • Don’t say “committed suicide” (like “committed a crime”) and use instead “died by suicide.”
  • When someone dies by suicide, especially students in schools, refrain from covering vigils because this type of attention can encourage copycat suicides.

More best practices for writing about suicide responsibly, compiled by Poynter, can be found here.

Yasmin Bendaas

Yasmin Bendaas is a Science writer.  A North Carolina native, she received her master’s degree in Science & Medical Journalism at UNC Chapel Hill, where she was a Park Fellow. She received her Bachelor of Arts in anthropology in 2013 from Wake Forest University, where she double-minored in journalism and Middle East and South Asia studies. As an undergraduate student, Bendaas gained insight into public health when she interned at the Kate B. Reynolds Charitable Trust, a statewide grantmaker focused on rural health, including access to primary care, diabetes, community-centered prevention, and mental health and substance abuse. 

As a journalist, Bendaas has been funded twice by the Pulitzer Center on Crisis Reporting for fieldwork in Algeria — first to cover a disappearing indigenous tattoo tradition, and again to look at how climate change affects rural sheepherding practices.