The National Rural Health Association (NRHA) is a national nonprofit membership organization that provides leadership on rural health issues. Through discussion and exploration, the NRHA works to create a clear national understanding of rural healthcare, its needs, and effective ways to meet them. Headquarted in Kansas City, Missouri, with a government affairs office in Washington, D.C., the NRHA is composed of individual, organizational and community members who share a common interest in rural health. Its primary mission is to provide leadership for improving the health and healthcare of rural Americans through education, communications, research and advocacy.

The association works toward several basic goals:

• To identify and represent the healthcare needs and views of rural America
• To increase understanding of health and healthcare problems unique to rural areas
• To provide a forum for the exchange and distribution of ideas, information, research and methods relative to the improvement of rural health
• To build coalitions for addressing rural concerns
• To develop and promote solutions to rural healthcare problems at the local, regional and national levels

The NRHA makes a tangible difference in the lives of rural Americans with programs, projects and initiatives designed to improve the health and well-being of the people living in rural and frontier areas.

Mental Health Needs of Rural Women
True to its calling to assist rural people, Representatives of the National Rural Health Association (NRHA) and the Committee on Rural Health of the American Psychological Association (APA) met with Congressional representatives recently to release the findings of the APA’s new report, “The Behavioral Health Needs of Rural Women.”

The new report from the APA “attempts to direct attention to this underrepresented. This knowledge will help psychologists and other health professionals to more effectively plan and deliver services to this population.” The report identifies the most commonly studied psychological disorder in rural areas as depression and goes on to identify the causes of depression among rural women, often sources that are either unique to rural life or at least more pronounced than in the metropolitan areas.

Among the main causes of depression are stressful life events such as isolation, weather problems, the declining farm economy with resulting unpredictable and irregular income and the lack of social, educational and child care resources, which are often more acute in rural environments.

The report identifies the barriers to treatment including:

• Stigma associated with mental illness.
• Lack of understanding about mental illnesses and their treatment.
• Lack of information about where to go for treatment.
• Inability to pay for care.

“Mental health is one of the most important issues facing rural residents today,” said Donna Williams, NRHA executive vice president.” We applaud the APA for this comprehensive report and are pleased to join them in making our legislators aware of the mental health needs of this often ignored segment of the population, rural women.”

In keeping with its belief in building from the bottom up, the NRHA has created a new membership category for rural community leaders from outside the healthcare arena. These concerned community leaders will receive the opportunity to expand their leadership skills, share challenges and solutions with their peers and have their voices heard on important issues to their communities at the state and national levels. By joining with NRHA’s current membership of healthcare professionals, this new contingent of community members will provide the NRHA with a more complete perspective on healthcare in rural America and its impact on the other critical areas of economic development and education.

Rural areas are unique, differing from urban areas in their geography, population mix and density, economics, lifestyle, values and social organization. Rural people and communities require programs that respond to their unique characteristics and needs. The NRHA recognizes these needs and wants to be part of the answer to rural families.

For further information about the NRHA, you can write to: NRHA, One West Armor Blvd., Suite 203, Kansas City, Mo. You can also contact them at 816/756-3140; fax 816/756-3144; e-mail: mail@NRHArural.org or visit their website at www.NRHArural.org.

No Place to Hide: Substance Abuse in Rural America Report
by Susan E. Foster

For anyone who thought that drug and alcohol abuse was a problem largely confined to urban areas, a study released earlier this year by the National Center on Addiction and Substance Abuse at Columbia University (CASA) shattered that illusion. The center’s report found that smoking, drinking and drug use among young teens is higher in rural America than in the nation’s large urban centers.

The study, first comprehensive assessment of substance abuse by population centers, reported that by any measure, the drug crisis is as common on Main Street as in Manhattan. The disturbing conclusions include the discovery that eighth graders living in rural America are:

• 104 percent likelier to use amphetamines, including methamphetamine, than those in urban areas
• 50 percent likelier to use cocaine
• 34 percent likelier to smoke marijuana
• 83 percent likelier to use crack cocaine
• 29 percent likelier to drink alcohol
• more than twice as likely to smoke cigarettes
• nearly five times likelier to use smokeless tobacco

The study also found that adult drug use is about equal across communities of all sizes. Cocaine, crack, heroin and marijuana are reported to be easy to obtain regardless of location.

For mid-size cities and rural areas, the consequences of substance abuse — such as increased crime, child abuse and neglect, health, social and other costs — are similar to those in larger cities. Yet smaller cities and rural areas are less equipped to deal with these consequences.

Compounding the problem, as another study released in May clearly shows, is the failure of primary care physicians to recognize or correctly diagnose alcohol or drug use in their patients. According to Missed Opportunity: The Center on Addiction and Substance Abuse National Survey of Primary Care Physicians and Patients, nine out of 10 — 94 percent —of primary care physicians fail to diagnose substance abuse when presented with early symptoms of alcohol abuse in an adult patient. Forty-one percent of pediatricians fail to diagnose illegal drug abuse when presented with a classic description of a drug-abusing teenage patient.

The survey reveals that physicians feel unprepared to diagnose substance abuse and lack confidence in the effectiveness of treatment. Only a small percentage of physicians consider themselves “very prepared” to diagnose alcoholism (19.9 percent), illegal drug use (16.9 percent) and prescription drug abuse (30.2 percent). In sharp contrast, 82.8 percent feel “very prepared’ to identify hypertension; 82.3 percent, diabetes and 44.1 percent, depression.

Physicians may miss or misdiagnose a teenager’s or an adult’s substance abuse because of lack of adequate training in medical school, residency or continuing medical education courses; skepticism about treatment effectiveness or discomfort discussing substance abuse, time constraints and patient resistance. A majority of physicians (57.7 percent) say they don’t discuss substance abuse with their patients because they believe their patients lie about the facts, and nearly 85 percent of patients agree.

What Can Be Done?
Parents, teachers, physicians and others who can prevent substance abuse by teens all have a role to play. They can learn to spot the symptoms of substance abuse and know what to do about it. Primary care physicians should screen their patients for substance abuse and be responsive to symptoms that may signal abuse of alcohol, drugs and tobacco use.

Medical schools, residency programs and continuing medical education courses should provide the training physicians need to spot and deal with substance abuse. Licensing boards and residency review committees of the primary care specialties also should mandate strong requirements regarding competency to diagnose substance abuse and addiction, learning to know how and where to refer patients for appropriate treatment. Medicare, Medicaid, private insurers and managed care should expand coverage for substance abuse treatment services and pay physicians to talk to patients about substance abuse. Primary care physicians should screen their patients for substance abuse and be responsive to a cluster of symptoms. However, small towns and rural areas will need help, such as resources to attract trained health and treatment workers, alcohol and drug counselors and school nurses, establish drug courts, train local police and sheriffs and, where necessary, increase their capacity with skilled personnel and new equipment. Local leaders also must be provided with the expertise and resources to develop model efforts that mobilize all the available resources — local, state and federal — to solve this problem in the most effective way.

The most important lesson CASA has learned is that if you can keep children from using tobacco and illicit drugs and abusing alcohol until they are 21 years old, they are virtually certain never to begin. The alarming rate of substance use by young teens in our rural areas is a stark reminder that there is no place to hide in America from the problems of substance abuse, and furthermore, it is a clarion call to action.

Susan E. Foster is the Vice President and Director of Policy Research and Analysis at The National Center on Addiction and Substance Abuse at Columbia University. She may be contacted by e-mail at: sf179@columbia.edu.